clinical_procedures_in_laser_skin_rejuvenation__series_in_cosmetic_and_laser_therapy_

Clinical Procedures

in Laser Skin

Rejuvenation

Prelims Carniol-8028.qxd 8/23/2007 10:37 AM Page i

SERIES IN COSMETIC AND LASER THERAPY

Published in association with the Journal of Cosmetic and Laser Therapy

Already available

1. David Goldberg.

Fillers in Cosmetic Dermatology. ISBN: 1841845094

2. Philippe Deprez.

Textbook of Chemical Peels. ISBN: 1841844950

3. C William Hanke, Gerhard Sattler, Boris Sommer.

Textbook of Liposuction. ISBN 1841845329

Of related interest

1. Robert Baran, Howard I Maibach.

Textbook of Cosmetic Dermatology, 3rd edition. ISBN: 1841843113

2. Anthony Benedetto.

Botulinum Toxin in Clinical Dermatology. ISBN: 1842142445

3. Jean Carruthers, Alistair Carruthers.

Using Botulinum Toxins Cosmetically. ISBN: 1841842176

4. David Goldberg.

Ablative and Non-Ablative Facial Skin Rejuvenation. ISBN: 1841841757

5. David Goldberg.

Complications in Cutaneous Laser Surgery. ISBN: 1841842451

6. Nicholas J Lowe.

Textbook of Facial Rejuvenation. ISBN: 1841840955

7. Shirley Madhere.

Aesthetic Mesotherapy and Injection Lipolysis in Clinical Practice.ISBN: 1841845531

8. Avi Shai, Howard I Maibach, Robert Baran.

Handbook of Cosmetic Skin Care. ISBN: 1841841793

Prelims Carniol-8028.qxd 8/23/2007 10:37 AM Page ii

Clinical Procedures

in Laser Skin

Rejuvenation

Edited by

Paul J Carniol MD FACS

Cosmetic Laser and Plastic Surgery

Summit, NJ

USA

Neil S Sadick MD FAAD FAACS FACP FACPh

Sadick Aesthetic Surgery and Dermatology

New York, NY

USA

Prelims Carniol-8028.qxd 8/23/2007 10:37 AM Page iii

© 2007 Informa UK Ltd

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

Healthcare is a trading division of Informa UK Ltd. Registered Office: 37/41 Mortimer Street, London W1T 3JH. Registered in England

and Wales number 1072954.

Tel: +44 (0)20 7017 5000

Fax: +44 (0)20 7017 6699

Website: www.informahealthcare.com

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any

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the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 0LP.

Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would

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

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

Library of Congress Cataloging-in-Publication Data

Data available on application

ISBN-10: 0 415 41413 X

ISBN-13: 978 0 415 41413 5

Distributed in North and South America by

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Within Continental USA

Tel: 1 (800) 272 7737; Fax: 1 (800) 374 3401

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Email: [email protected]

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Composition by C&M Digitals (P) Ltd, Chennai, India

Printed and bound in India by Replika Press Pvt Ltd

Prelims Carniol-8028.qxd 8/23/2007 10:37 AM Page iv

List of contributors vii

Note on outcomes x

1 Laser safety 1

William Beeson

2 Evaluation of the aging face 11

Philip J Miller

3 Carbon dioxide laser resurfacing,

Fractional resurfacing and YSGG resurfacing 17

Dee Anna Glaser, Natalie L Semchyshyn and Paul J Carniol

4 Erbium laser aesthetic skin rejuvenation 31

Richard D Gentile

5 Complications secondary to lasers

and light sources 45

Robert M Adrian

6 Nonablative technology for treatment

of aging skin 51

Amy Forman Taub

7 Lasers, light, and acne 69

Kavita Mariwalla and Thomas E Rohrer

8 Treatment of acne scarring 89

Murad Alam and Greg Goodman

9 Nonsurgical tightening 103

Edgar F Fincher

10 Laser treatment of pigmentation

associated with photoaging 111

David H Ciocon and Cameron K Rokhsar

11 Management of vascular lesions 125

Marcelo Hochman and Paul J Carniol

12 Laser treatment for unwanted hair 135

Marc R Avram

13 Non-invasive body rejuvenation

technologies 139

Monica Halem, Rita Patel, and Keyvan Nouri

14 Treatment of leg telangiectasia with

laser and pulsed light 157

Mitchel P Goldman

15 Photodynamic therapy 173

Papri Sarkar and Ranella J Hirsch

16 Adjunctive techniques I: the bioscience of

the use of botulinum toxins and fillers

for non-surgical facial rejuvenation 181

Kristin Egan and Corey S Maas

17 Adjunctive techniques II: clinical aspects

of the combined use of botulinum toxins

and fillers for non-surgical facial rejuvenation 191

Stephen Bosniak, Marian Cantisano-Zilkha,

Baljeet K Purewal and Ioannis P Glavas

18 Adjunctive techniques III:

complementary fat grafting 205

Robert A Glasgold, Mark J Glasgold

and Samuel M Lam

Index 219

Contents

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Prelims Carniol-8028.qxd 8/23/2007 10:37 AM Page vi

Robert M Adrian MD FACP

Center for Laser Surgery

Washington, DC

USA

Murad Alam MD

Departments of Dermatology,

Otolaryngology, and Surgery

Northwestern University

Chicago, IL

USA

Marc R Avram MD

Department of Dermatology

New York Presbyterian Hospital-Weill Medical

College at Cornell Medical Center

New York, NY

USA

William Beeson MD AAFPRS AACS

Beeson Aesthetic Surgery Institute

Carmel, IN

USA

Stephen Bosniak † MD

Marian Cantisano-Zilkha MD

Manhattan Eye, Ear and Throat Hospital

New York, NY

USA

Paul J Carniol MD

Cosmetic Laser and Plastic Surgery

Summit, NJ

USA

David H Ciocon MD


Albert Einstein College of Medicine

New York, NY

USA

Kristin Egan MD

Department of Otolaryngology

UCSF

San Francisco, CA

USA

Edgar F Fincher MD PhD

The David Geffen School of Medicine at UCLA

and

Moy-Fincher Medical Group

Los Angeles, CA

USA

Richard D Gentile MD

Facical Plastic and Aesthetic Laser Center

Youngston, OH

USA

Dee Anna Glaser MD

Dermatology Department

St Louis University

St Louis, MO

USA

Mark J Glasgold MD

Department of Surgery

Robert Wood Johnson Medical School

University of Medicine and Dentistry of New Jersey

Piscataway, NJ

USA

Robert A Glasgold MD

Department of Surgery

Robert Wood Johnson Medical School

University of Medicine and Dentistry of New Jersey

Piscataway, NJ

USA

Contributors

Prelims Carniol-8028.qxd 8/23/2007 10:37 AM Page vii

Ioannis P Glavas MD

Oculoplastic Surgery

Manhattan Eye, Ear and Throat

New York, NY

USA

Mitchel P Goldman MD

LaJolla Spa

LaJolla, CA

USA

Greg Goodman MD


Minash University

Melbourne

Australia

Monica Halem MD


Miller School of Medicine

University of Miami

Miami, FL

USA

Ranella J Hirsch

Skin Care Doctors

Cambridge, MA

USA

Marcelo Hochman MD

The Facial Surgery Center

Charleston, SC

USA

Samuel M Lam MD

Willow Bend Wellness Center

Lam Facial Plastic Surgery Center and

Hair Restoration Institute

Plano,TX

USA

Corey S Maas MD


UCSF

and

The Maas Clinic

San Francisco, CA

USA

Kavita Mariwalla MD


Yale School of Medicine

New Haven, CT

USA

Philip J Miller MD FACS


New York University School of Medicine and

The NatraLook ProcessTM

and East Side Care

New York, NY

USA

Keyvan Nouri MD



University of Miami

Miami, FL

USA

Rita Patel MD



University of Miami

Miami, FL

USA

Baljeet K Purewal MD

Department of Opthalmology

Lutheran Medical Center

Brooklyn, NY

USA

Thomas E Rohrer MD


Boston University School of Medicine

and

Skin Care Physicians of Chestnut Hill

Chestnut Hill, MA

USA

Cameron K Rokhsar MD FAAD FAACS


Albert Einstein College of Medicine

New York, NY

USA

viii List of contributors

Prelims Carniol-8028.qxd 8/23/2007 10:37 AM Page viii

Neil S Sadick MD

Sadick Aesthetic Surgery and Dermatology

New York, NY

USA

Papri Sarkar MD


Harvard Medical School

Boston, MA

USA

Natalie L Semchyshyn MD

Dermatology Department

St Louis University

St Louis, MO

USA

Amy Forman Taub MD

Advanced Dermatology

Northwesten University Department of Dermatology

Lincolnshire, IL

USA

List of contributors ix

Prelims Carniol-8028.qxd 8/23/2007 10:37 AM Page ix

Although every effort has been made to ensure that

information about techniques and equipment is pre-

sented accurately in this publication, the ultimate

responsibility rests with the practitioner physician.

Use of these techniques or items of equipment does

not guarantee outcomes or that they are the optimal

procedures available. Procedure results and potential

complications frequently vary between patients:

physicians must evaluate their patients individually

and make appropriate decisions about treatment

based on each analysis. Although it is not always nec-

essary, when a physician initiates any new therapy on a

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

areas should be considered for patient response before

initiating the full treatment itself.

Neither the publishers, nor the editors, nor the

authors can be held responsible for errors or for any

consequences arising from the use of information con-

tained herein. For detailed instructions on the use of

any product or procedure discussed herein, please

consult the instructional material issued by the manu-

facturer. Some of the use of technology and proce-

dures described in this text may be ‘off label’ as

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

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

used at the discretion of the physician.

Note on outcomes

Prelims Carniol-8028.qxd 8/23/2007 10:37 AM Page x

INTRODUCTION

Surgical lasers have opened a new vista for aesthetic

surgery. Laser skin resurfacing is commonplace, as is

laser treatment for vascular lesions, varicosities, and

laser hair removal. Laser blepharoplasty and facelifts,

as well as the employment of the laser in endoscopic

facial surgery, are becoming commonplace.With the

increasing varieties of lasers and the numerous wave-

lengths available, laser safety has become a more

complex issue.1

It is incumbent upon the surgeon to

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

also the entire operating room staff.

With the increasing trend for more and more proce-

dures to be performed in an ambulatory surgical setting,

we find that medical lasers are commonly being

employed in small clinics or office surgical settings. Not

only physicians, but podiatrists, dentists, and others use

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

requirements and principles for the safe use of lasers are

no less stringent in this setting than when the lasers are

employed in a large metropolitan hospital. Laser safety

standards apply equally in all of these settings.

When a physician utilizes a medical laser, they have a

medical, legal, and ethical responsibility to be aware of

the requirements for the safe use of lasers in healthcare

facilities.This means that the physician should be trained

in laser safety and be knowledgeable as to local and fed-

eral regulations, as well as the advisory standards and

professional recommendations for the use of lasers in

their applicable speciality.

CLASSIFICATION OF LASERS

Medical lasers are classified in the USA in accordance

with the Federal Laser Product Performance Standard,

which essentially classifies lasers based on the ability of

the laser beam to cause damage to ocular and cuta-

neous structures. The Food and Drug Administration

(FDA) Center For Devices and Radiologic Health

(CDRH) has the responsibility for implementing and

enforcing the Federal Laser Product Performance

Standard and Medical Device Amendment to the

Food, Drug, and Cosmetic Act.

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

IV. Medical lasers can be divided into two broad cate-

gories: those in the visible and mid-infrared range

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

the retina presents the primary ocular hazard; and

those in the ultraviolet and infrared regions, in which

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

general, class IV laser systems present a fire hazard in

addition to the ocular and cutaneous hazards associ-

ated with class III-B lasers.

A class I laser is considered to be incapable of pro-

ducing damaging levels of laser emission. Class II

applies only to visible laser emissions, which may be

viewed directly for time periods ≤ 0.25 s: the aversion

response time (aversion response is defined as move-

ment of the eyelid or head to avoid exposure to a nox-

ious stimulant or bright light). This is essentially the

blink reflex time. Only if one purposely overcomes

one’s natural aversion response to bright light can a

class II laser pose a substantial ocular hazard. Class III

lasers may be hazardous by direct exposure or expo-

sure to specific reflection. A subcategory of class III

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

power. These pose a moderate ocular problem under

specific conditions where most of the beam enters the

eye. The aiming beam or alignment beam for a laser

usually falls within this range, and can be hazardous

when viewed momentarily if the beam enters the eye.

For this reason, one must take particular caution when

1. Laser safety

William Beeson

01 Carniol-8028.qxd 8/23/2007 3:30 PM Page 1

using the alignment beam and be aware that ocular

damage can occur with misuse. Class III-B lasers

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

momentary viewing of class III-B lasers is potentially

hazardous. Class IV lasers are those emitting > 500 mW

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

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

ocular injury, and fire hazards.

REGULATIONS

In addition to FDA enforcement, other rules and regu-

lations apply to the use of lasers in the medical setting.

In recent years, the Occupational Safety and Health

Administration (OSHA) has stressed the need for

employers to inform and educate workers on work-

place risks. This has been of particular importance

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

Department of Labor has developed guidelines for

Laser Safety Hazard Assessment, which pertain to the

use of medical lasers.2

Compliance with OSHA rules is an important com-

ponent of a laser safety program.

HAZARD CLASSIFICATION

There are no specific OSHA guidelines for assessing

the level of compliance of a facility providing laser

facelifts and laser blepharoplasty. However, the

American National Standards Institute (ANSI) stan-

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

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

OSHA are made under the ‘general duty clause’,

which states that there is a shared duty between the

employer and employee for establishing and maintain-

ing a safe working environment. The employer has a

duty to provide the proper safety equipment, appro-

priate education and training, and a work environment

free of known potential risks and hazards. The

employee has a duty to attend the training, use of

personal protective equipment, and follow safe work

practices at all times. OSHA compliance officers

respond to requests, complaints, and accidents

reported. Facilities must demonstrate that they have

established policies and procedures, identified proper

personal protective equipment, implemented a

program for education of all employees who might be

at risk for exposure to laser hazards, performed and

documented periodic safety audits, and assured ongo-

ing administrative control in program surveillance.3

In addition to governmental agencies such as the

FDA, OSHA, and state departments of health,

nongovernmental accrediting and review organiza-

tions also have guidelines and recommendations for

the laser safety in healthcare facilities. The ANSI is a

nonregulatory body that promulgates thousands of

safety standards in the USA.Working committees have

representation from industry, the military, regulatory

bodies, user groups, research and educational facili-

ties, and professional organizations. The ANSI also

participates in international standard work through

groups such as the International Organization for

Standardization (ISO).The main objective of the ANSI

is to establish and maintain benchmarks for national

safety through consensus documents.

ANSI Z-136.3 has become the expected laser safety

standard in healthcare. Although it is not regulatory, it

has taken on the impact of regulations through its wide

acceptance. It is used by the OSHA and many accredit-

ing organizations such as the Joint Commission

(previously the Joint Commission on Accreditation of

Healthcare Organizations, JCAHO) and the Accredita-

tion Association of Ambulatory Healthcare (AAAHC),

and it is exhibited as reference during litigations.The

standard provides a comprehensive guide for the

development of administrative and procedural control

measures that are necessary for maintaining a safe laser

environment and should be used as the cornerstone

for all clinical laser programs.

It is important to develop a risk management

process regarding the safe use of lasers, consisting of

written policies and procedures, as well as ongoing

evaluations of compliance, and demonstrating timely

and appropriate responses to incidents or accidents

that could occur.Typically, the person responsible for

the management of the laser safety–risk management

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

136.3 standard defines the laser safety officer as ‘an

individual with the training, self-study, and experience

to administer a laser safety program. This individual

(who is appointed by the administration) is authorized

and is responsible for monitoring and overseeing the

control of laser hazards. The laser safety officer shall

effect the knowledgeable evaluation and control of

2 Clinical procedures in laser skin rejuvenation


laser hazards by utilizing, when necessary, the appro-

priate clinical and technical support staff and other

resources.’4

The laser safety officer should be responsible for

verifying the classifications of the laser systems, hazard

analysis, ensuring appropriate control measures are in

effect, approving all policies and procedures, ensuring

that protective equipment is available, overseeing

instillation of equipment, ensuring that all staff are

properly trained, and maintaining medical surveillance

records. In private practice in small clinical settings,

the physician who owns and runs the practice or clinic

is very likely to serve as the laser safety officer.

All laser users must adhere to the following principles:

• Laser safety requirements are no less stringent in

private practice than in a hospital setting.

• The individual laser user must know all profes-

sional standards and regulations and be thoroughly

trained in laser safety.

• The user must ensure that the entire staff are

properly trained in the safe use of lasers.

• There must be an appointed laser safety officer.

• The user must establish and follow standard-based

policies and procedures.

It is important that safety audits be utilized in a routine

manner to be sure that laser safety programs are being

adhered to. ANSI standards require an audit at least

annually. A laser safety audit is an assessment of all

equipment, supplies, and documents involved in per-

forming laser treatments in a facility. It is supervised

by the laser safety officer and consists of four basic

components:

1. Inventory all equipment and develop a checklist.

2. Inspect every item on the checklist.

3. Document results.

4. Identify action items based on audit results.

In addition to the ANSI, voluntary healthcare accredit-

ing organizations such as the Joint Commission and the

AAAHC all have standards that apply to the use of

lasers in the medical environment, including the office

surgical setting.

Laser regulation at state and local government levels

has increased significantly in recent years. Regulations

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

regulatory bodies, such as medical licensing boards

and departments of health, to address laser safety issues

by setting standards for credentialing and training.

Regulations will usually dictate the type of individual or

individuals who are qualified to perform laser treat-

ments and prescribe levels of training to document cur-

rent competency with each type of laser being used.

Almost all require personnel using lasers in healthcare

arenas to be cognizant of basic laser safety issues.

Some states allow only physicians to perform laser

surgery, while others allow physician assistants and

advanced practice nurses to perform laser treatments.

Some will allow nurses and other allied health person-

nel to perform laser treatments, but only with the direct

supervision of a trained physician. Still other states

permit the use of lasers by paramedical personnel

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

current trend is for increased supervision and training.

While some states may not directly address laser

surgery, they do so indirectly by requiring accredita-

tion of ambulatory surgical or office surgical units. In

these cases, the medical licensing board has subrogated

authority to a national accrediting organization such as

the Joint Commission, the AAAHC, or the American

Association for Accreditation of Ambulatory Surgery

Facilities (AAAASF). Each of these organizations has

developed specific standards that can be applied to

laser use in the medical setting.

In 2005, the Joint Commission, currently in its sen-

tinel event program, adopted measures for its accredited

organizations to utilize in an attempt to reduce the likeli-

hood of patient injury from fire resulting from the use of

lasers in the operating room. Since the Joint Commission

accredits the vast majority of hospitals in the USA and

since all Joint Commission-accredited organizations

using medical lasers must adhere to these recommended

standards, one could argue from a legal standpoint that

these are de facto ‘community standards’. The legal

implications of not meeting the accepted ‘community

standards’ if a patient has an injury when being treated

with a medical laser are significant.

It is imperative that any person in a medical practice

who treats with a laser adhere to strict regulations

regarding scope of practice, licensing requirements, and

standardized procedures. It is also extremely important

for the physician’s malpractice insurance carrier to

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

is essential to know if the person doing the laser

Laser safety 3


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

insurance company will not insure someone who is ille-

gally practicing outside the scope of his or her license,

etc. Health practitioners cannot ignore the importance

of this issue for overall success and safety.

At present, there are no national, state, or local cer-

tifications or licensing agencies to qualify the compe-

tency of surgeons, nurses, or technicians in the safe

use of lasers. There is no standardized or universally

accepted certification or training organization. It is,

therefore, important to consider the ANSI guidelines

as well as the recommendations of various professional

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

Box 1.1 Recommendations for establishing laser program and

clinical setting

1. Check with medical licensing board in your state

regarding laser regulations

2. Develop laser safety protocols for your facility.

Document training for yourself and your staff

3. Consider formal laser safety officer training and

appoint a laser safety officer

4. Monitor changes in accreditation standards and ANSI

Z-136.3 guidelines

5. Check with your medical liability carrier. Obtain

delineation of coverage for yourself and your staff

regarding the use of lasers in your practice

Box 1.2 Information resources for laser safety guidelines

• American National Standards Institute (ANSI), 11

West 42nd Street, New York, NY 10 036

• Laser Institute of America, 12424 Research Parkway,

Suite 125, Orlando, FL 32826

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

Devices and Radiologic Health (CDRH), 9200

Corporate Boulevard, Rockville, MD 20850

• US Department of Labor, Occupational Safety and

Health Administration (OSHA), 200 Constitution

Avenue, NW,Washington, DC 20210

• Joint Commission (formerly JCAHO), 1 Renaissance

Boulevard, Oak Brook Terrace, IL 60181

• Accreditation Association of Ambulatory Healthcare

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

Skokie, IL 60077

BIOLOGICAL HAZARDS OF LASERS

Laser hazards can essentially be divided into non-

beam-related hazards and beam-related hazards. The

latter are unique to lasers, and pose the need for

special attention and safety requirements when using

lasers in the medical setting.This relates to the optical

radiation hazard, which can result in damage to both

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

vulnerable to laser light, the ocular hazards are consid-

ered of paramount importance. In most cases, the eye

has a natural protective mechanism that limits retinal

exposure to irritants.The blink reflex occurs at about

every 0.25 s and accounts for the aversion response

previously described. However, the intensity of some

laser beams can be so great that injury can occur

before the protective lid reflex. This usually happens

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

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

acoustic effects and heat flow, significant tissue damage

can occur, leading to severe retinal impairment. For

this reason, it is not uncommon to lose all visual func-

tion when exposed to even minimal amounts of laser

energy when that energy is focused on critical areas of

the retina such as the fovea. Such visual loss is gener-

ally permanent, since the neural tissue of the retina has

minimal ability to replicate.

Injury to the cornea and the anterior segment of the

eye is possible from wavelengths in the ultraviolet and

in the infrared beyond 1400 nm.When injury occurs

to the cornea, it is usually superficial and involves the

corneal epithelium. Re-epithelization usually occurs

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

results. However, deeper penetration can result in

corneal scaring and permanent loss of vision. Carbon

dioxide (CO2) laser wavelengths pose such a potential

risk. Excimer lasers operate in the ultraviolet range and

pose a potential hazard to the cornea. Ocular injury can

occur from direct penetration of a focused beam.

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

accidental ocular exposure to a reflected beam.

Protection from reflected laser beams can be difficult.

The most commonly employed surgical laser today is

the CO2

laser. Since the CO2

laser wavelength of

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

so this potential hazard can go unnoticed. For this



reason it is imperative that precautions be taken at all

times when using CO2

lasers.This is also true of Ho:YAG

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

lasers, whose emissions are in the visible region.

Reflections most commonly occur from flat metallic

mirror-like surfaces such as nasal speculums or surgical

instruments. Black anodized or abraded–roughened

surfaces can reduce (but not totally eliminate) the

potential for beam reflection. Roughening a surface is

generally thought to be more effective than ebonizing

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

Because of the potential for ocular injury secondary to

beam reflection, it is imperative that proper protec-

tion be afforded to the patient and all operating room

personnel at all times when lasers are in use.

Ordinary optic glass protects against all wavelengths

shorter than 300 nm and longer than 2700 nm.

Polycarbonate safety glasses with sideshields are

suitable for use with the CO2

lasers if the power is

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

While polycarbonate glasses may be adequate, there

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

even when wearing protective eyewear, one should not

focus the laser beam directly on the shield for any

length of time. Laser safety glasses should always have

sideshields.The optical density rating should be listed

on the sidebar of the eyeglasses.

It is important to realize that many lasers radiate at

more than one wavelength. For this reason, eyewear of

appropriate optical density for a particular wavelength

could be completely inadequate at another wavelength

radiated by the same laser.This is particularly impor-

tant for lasers that are tunable over broad wavelength

bands.

When a patient is within a nominal hazard zone

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

is a space within which the level of the direct,

reflected, or scattered radiation during normal opera-

tion exceeds the acceptable maximal permissible

exposure (MPE). Proper eye protection may range

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

cases, corneal protectors provide the best protection.

Plastic corneal protectors have become popular.

However, in some cases, plastic shields can transfer

thermal energy to the cornea, with resultant injury.

This is especially true with darker-colored shields.6

CUTANEOUS INJURY

While ocular injury is the most devastating direct

beam laser injury, cutaneous hazards do exist.The skin

can be injured either through a photochemical mecha-

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

third-degree burns can be induced by visible and

infrared laser beam exposure. Such injuries have been

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

geons reporting unintentional burns to either patients

or operating room personnel.7,8

In most cases, moist

towels draped around the operative site and fire-

resistant surgical drapes will provide proper protection.

NON-BEAM-RELATED HAZARDS

In addition to direct laser beam hazards to the eye and

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

considered. These include electrical hazards, laser-

generated airborne contaminants (laser plume), waste

disposal of contaminated laser-related materials

such as filters, and laser-generated electromagnetic

interference.

All medical lasers must operate in compliance with

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

and local regulations. Electrical hazards can be related

to damaged electrical cords and cables, inadequate

grounding, and the use of conductive liquids in the

vicinity of the laser when it is in operation. These

problems can usually be minimized with an appropri-

ate laser maintenance program by qualified biomedical

engineers and adherence to appropriate laser safety

guidelines when operating electrical equipment in the

surgical environment.

Laser-generated airborne contaminants present a

significant problem. Studies have shown the presence

of gaseous compounds, bio-aerosols, dead and live

cellular materials, and viruses in the laser plume.The

laser plume can cause ocular and upper respiratory

tract irritation. The unpleasant odors of the laser

plume can cause discomfort to both the physician and

the patient.The laser plume can cause ocular irritation,

and may be even more of a problem for individuals

who wear soft contact lenses, as the particles can

permeate the lenses and cause prolonged irritation.

Laser safety 5


However, of greatest concern is the mutagenic and

carcinogenic potential of the compounds contained in

the plume.At a time when the threat from bloodborne

pathogens has led to enhanced awareness of the risks of

contact with blood and blood byproducts, the practice

of universal precautions has taken on a new meaning.

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

evacuator is held 2 cm from the source of the laser

plume, aerosolization of the particles is minimal. The

suction created in the evacuator tubing is important.

This results in the creation of a vortex that removes

mutagenic debris and prevents aerosolization of the

carbonized particles. (The latter impregnate the tub-

ing, which should therefore be treated as a biohazard

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

operating room suction and suction tubing do not pro-

vide adequate evacuation of the laser plume.

While surgical masks may help reduce laser expo-

sure, their use alone is not adequate. At present, there

is no mask respirator on the market that excludes all

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

ria, and other hazards. Surgical masks are not designed to

protect from plume contents. Rather, they are intended

to protect patients from the surgeon’s contaminated

nasal or oral droplets. Specialized surgical masks that fil-

ter out particles down to 0.3 µm with high efficiency are

available and can help to decrease the inhalation of laser

plume particles. While some laser masks are of suffi-

ciently increased density to remove a higher proportion

of laser-generated particles, their use alone is not ade-

quate.9As with smoke evacuator tubing, filters will be

impregnated with potentially dangerous materials, and

should therefore be treated as hazardous waste.

Lasers can create electromagnetic interference.

Electromagnetic radiation generated by lasers can

interfere with other sensitive electronic equipment

present in the facility, such as cardiac telemetry equip-

ment.This can also affect patients who have pacemak-

ers. The electromagnetic interference potential of a

laser system is normally described in the manufac-

turer’s labeling, or it can be determined by a biomed-

ical engineer with laser safety officer experience.

FIRE HAZARD

Operating room fires are rare – but when such blazes

do occur, they can be lethal. Potentially flammable

materials such as gauze, cotton, paper surgical drapes,

and plastic endotracheal tubes can be ignited in the

operating room by the laser, and the oxygen-enriched

environment can intensify fires.

Accidental fires are a well-known hazard associated

with laser treatment. It has been estimated that com-

bustion occurs in 0.4–0.57% of CO2

laser airway pro-

cedures.10

Others have demonstrated that, in the

presence of oxygen concentrations of 21–25%,

polyvinyl chloride, red rubber, and silicone endotra-

cheal tubes can rapidly ignite when struck with CO2

laser beam.The threshold for ignition is increased with

the addition of helium to the oxygen concentration.

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

density and acts as a heat sink, delaying combustion for

about 20 s. Laser fires have also resulted from the igni-

tion of polyvinyl chloride endotracheal tubes wrapped

in aluminum tape.11

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

Class IV laser systems (emitting > 500 mW radiant

power) present a fire hazard in addition to the ocular

and cutaneous hazards associated with class III-B

lasers. Most surgical lasers fall within this class.

The basic elements of a fire are always present during

surgery.A misstep in procedure or a momentary lapse of

caution can quickly result in a catastrophe. Slow reaction

to the use of improper firefighting techniques and tools

can lead to damage, destruction, or death.

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

understand and to employ the principles of the ‘fire

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

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

safety in this regard is to control all three components.

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

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

be extremely varied – often something that one would

not immediately think of, such as an overhead surgical

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

light left on a surgical drape.

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

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

that one would not likely consider, such as a petro-

leum-based ophthalmologic ointment. Fuels com-

monly encountered in surgery can be divided into five

categories: the patient, prepping agents, linens, oint-

ments, and equipment.

The key ‘oxidizer’ in the operating room is the

oxygen-rich environment. An oxidizer can be thought



of in this context as something that facilitates ignition

and combustion. Decades ago, anesthesiologists recog-

nized the hazards of flammable anesthetic agents in the

operating room and eliminated them.Today, oxygen is

one of the key components to deal with in regards to

operating room fires. In the great majority of such

fires that have been reviewed, an oxygen-rich environ-

ment and ineffective management of this ‘oxidizer’

were the key factors in the mishap.

Preventing fires in the operating room is dependent

on disrupting the fire triangle, as all of its components

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

control the heat source, manage the fuels, and mini-

mize the oxygen concentration.

One of the most common errors is inadvertent

activation of the laser. Not infrequently, the surgeon

thinks that he or she is stepping on the cautery foot

pedal when they are actually stepping on the laser

pedal, which activates the dangling laser, whose beam

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

One of the most basic – but most effective – safety

measures is to eliminate the clutter of multiple foot ped-

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

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

equipment one is using in access range is extremely

important. ANSI standards dictate that there be a

laser-designated operator trained in the safe use of any

particular laser.The responsibility of the laser operator is

to release the laser from standby setting mode when the

surgeon requests its activation and to immediately place

the laser back on standby mode when the surgeon is fin-

ished.This markedly reduces the likelihood of inadver-

tent laser activation. It is essential that the laser operator

ensure that there is an appropriate ‘environment’ before

activating the laser.They should scan the room to ensure

that no flammable agents such as acetone or cleaning

agents are present, that all personnel are wearing appro-

priate eye protection, that the patient’s eyes are pro-

tected, and that the oxygen has been reduced to room air

levels before the laser, is activated.

Managing the potential ‘fuel’ source is important,

and requires delegation and advanced planning. Proper

prepping techniques are critical. If possible, the use of

alcohol-based prepping solutions should be avoided. It

is important that flammable prep solutions be

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

drapes under the patient, enabling fumes to accumu-

late and possibly be ignited. It is also important to be

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

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

flammable.

Minimizing the oxygen environment is extremely

important and must be done in concert with the anes-

thesiologist.This requires presurgical discussion regard-

ing how one plans to perform the procedure, the type of

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

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

the oxygen concentration being delivered to room air

levels during the time the laser is being activated and to

return immediately to supplemented levels when the

laser is deactivated.This requires coordination between

the surgeon and the anesthesiologist and the ability of

the surgeon to immediately terminate the laser use if the

anesthesiologist notes a precipitous drop in FiO2

on the

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

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

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

cases where higher levels of oxygen are required by the

patient, and alternating from supplemented oxygen to

room air is not possible, a helium and oxygen combina-

tion may serve to increase the safety margin when

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

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

concentration should be maintained below 40%.

Recommendations regarding anesthesia are summarized

in Box 1.3.

Box 1.3 Recommendations regarding anesthesia

• Oxygen should be used at the lowest possible

concentration

• Oxygen (or other gases) should never be directed

toward the laser field

• Any mixture of nitrous oxygen and oxygen should be

treated as if it were pure oxygen

• Helium can be used to increase the ignition threshold

• Laryngeal airways (with spontaneous respiration) are

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

analyzer can be utilized to ensure minimal leakage

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

filled with saline rather than air.The tube should be

wrapped in aluminum or copper tape

• Collared masks, nasal cannulas, or airway materials

should be avoided.

• Anesthetics that are administered either by inhalation

or topically should be nonflammable.

Laser safety 7


PREPARING FOR FIRES

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

prepared for fire is an inexpensive insurance and will

minimize the cost in dollars, loss in time, emotional

shock, injury, and possibly death. Preparation involves

a number of steps. The most important is practicing

fire drills to teach all staff about their responsibility

during a laser fire. This should be done similarly to

what is done for medical codes and other routine

disaster drills.

It is surprising how many individuals do not know

how to select a proper fire extinguisher or how to use

one. Most fire extinguishers operate according to the

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

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

handle to release the extinguishing agent, and Sweep

the stream over the base of the fire.

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

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

the demise of Halons as fire-extinguishing agents, CO2

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

operating room. Halons (bromofluorohydrocarbons)

are damaging to the environment and are no longer

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

available, it is the optimal one to use. Small CO2

fire

extinguishers have five-pound charges and weigh

approximately 15 pounds. This is easily enough for

most people to handle and small enough to mount

unobtrusively on the wall in the operating room near

the door. CO2

fire extinguishers are rated for use

against class B and class C fires in the operating room

setting, although they can be used effectively against

the kinds of class A fires that are likely to occur. CO2

fire extinguishers emit a fog of CO2

gas with liquid and

solid particles that rapidly vaporize to cool and smooth

the fire, while leaving no residue to contaminate the

patient. Dry powder fire extinguishers employ pri-

marily of ammonium sulfate, which is emitted in a

stream against the fire. The powder smothers, cools,

and to some extent disrupts the chemical reaction of

the fire. During use, the powder limits visibility and

covers everything in the surrounding area, which can

damage delicate equipment. The powder irritates the

mucous membranes and its long-term toxicity has

not clearly been determined. Using a powder fire

extinguisher in the operating room will make the

room and much of the equipment unusable for a

period of time. For these reasons, dry powder should

not be used as the first line of defense against operating

room fires. Pressurized-water fire extinguishers are

available, but are heavy and chiefly effective against

only class A fires.

If a laser fire should inadvertently occur, quick action

is imperative.Ventilation should be stopped and anes-

thetic gases discontinued.Then the tracheal tube, mask,

and nasal cannula should be removed.The fire should be

extinguished with normal saline.The patient should then

be mask-ventilated with 100% oxygen.The anesthesia

should be continued in order to facilitate injury assess-

ment to allow the patient to be stabilized. Iced saline

compresses should be applied to areas of burn.A flexible

nasal pharyngoscope or bronchoscope should be used to

survey the upper airway and laryngeal tissues to evaluate

the extent of injury. Foreign bodies and carbonized

debris should be removed. Copious irrigation with nor-

mal saline and Betadine soap can be used to remove car-

bonized debris from cutaneous burned areas. Xeroform

gauze and bacitracin ointment can be applied to areas of

minor cutaneous burns. If thermal injury has occurred in

the nasal airway, a light nasal packing with Xeroform

gauze can be used to stent the airway to treat thermal

damaged tissues.

Depending on the severity of injury, it may be

important to consider the use of intravenous steroids.

High-humidity environments should be provided and

oxygenation monitored. Patients may require ventila-

tory support for laryngeal edema as a potential prob-

lem. A chest X-ray should be considered in order to

obtain a baseline evaluation to monitor for ‘shock

lung’. Evaluation by other consultants such as a pul-

monologist or ophthalmologist should be considered

when appropriate. Systemic antibiotics such as

cephalosporins should be considered. In all but the

most minor cases, the patient should be observed

overnight.12

ENVIRONMENT OF CARE

Medical lasers should be used in the appropriate envi-

ronment.There should be proper electrical grounding



to minimize potential electrical shock. There should

be proper ventilation and the room should be of suffi-

cient size to enable the use of smoke evacuators, laser

equipment, and additional personnel needed for

proper laser instrumentation. Treatment should be

performed in a controlled area, which should limit

entry by unauthorized personnel. Proper warning

signs should be displayed at the entry and within the

controlled area. Only those properly trained in laser

safety should be admitted to the controlled area. All

open portals and windows should be covered or

restricted in such a manner as to reduce the transmis-

sion of laser radiation to levels at or below the appro-

priate ocular MPE for any laser used in the treatment

area. It should be noted that normal window glass has

an optical density in excess of 5.0 and therefore

should be appropriate for CO2

lasers at 10:600 µm.

Other lasers require the facility windows to have

additional coverings or filtering.

While it is important that the entryway to the laser

room or treatment area be secured, it is equally

important that emergency entry be permitted at all

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

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

locked door could prevent appropriate emergency

response. It is important to have proper safety equip-

ment within the treatment environment.This includes

proper eye protection for all staff, as well as the

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

Of equal importance is an appropriate laser plume

evacuation device. In most cases, standard surgical

wall suction does not suffice.

TRAINING

It is imperative that all personnel using medical lasers

be properly trained and that appropriate laser safety

protocol exist within each facility. Acceptable stan-

dards dictate that an individual designated as a laser

safety officer be in charge of developing criteria and

authorizing procedures involving the use of lasers

within the facility, and ensuring that adequate protec-

tive measures for control of laser hazards exist and that

there exist a mechanism for reporting accidents or

incidents involving the laser.

It is also important that accurate records be main-

tained for lasers, as well as laser-related injuries.

SUMMARY

Lasers can be employed in a variety of medical set-

tings.When used properly, lasers can provide dramatic

improvements in the quality of patient care. However,

as with any medical procedure, complications can and

do occur. Close adherence to standard accepted laser

safety protocols can dramatically reduce that risk and

improve the quality of patient care.

REFERENCES

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

New York: Springer-Verlag, 1992.

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

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

American National Standards Institute, 2004.

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

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

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

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

Health Care Facilities. New York: American National

Standards Institute, 2004.

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

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

Regulations, Occupational Health and Safety.

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

Safe Use of Lasers in Healthcare Facilities. New York:

American National Standards Institute.

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

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

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

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

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

Complications of cutaneus laser surgery. A survey. Arch

Dermatol 1987;103:345–9.

11. Baggish MS. Complications associated with CO2

laser

surgery in gynecology. Am J Obstet Gynecol 1981;

139:658.

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

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

Safety Recommendations. Dermatol Surg 1996;22:

699–702.

Laser safety 9


INTRODUCTION

In this chapter, we will explore the algorithm involved

in analyzing the aging face. But before we even begin

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

aged face?’

While the answer may seemingly be self-apparent,

further contemplation reveals a complexity not first

appreciated. For starters, when is the face considered

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

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

comprehensive and detailed understanding of the

pathophysiology of facial aging, which serves as the

foundation for our analysis?

WHAT IS AN AGED FACE

While the jury may still be out regarding when life

actually begins, one could argue that death begins at

the moment of conception! Life is nothing more than

the balance between anabolic activities and catabolic

activities. Throughout our life, the ratio of anabolic

and catabolic states simply switches. Somewhere along

that continuum, we begin to demonstrate findings on

the outside of our body, particularly the face, where

the catabolic process has increased its relative strength

compared with the anabolic process. From that move-

ment on, at different rates and in different ratios,

mixed with different environmental exposures, these

processes determine the resulting ‘aged appearance’ of

any one person.

What is considered an aged face in one society may

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

of the tremendous respect and honor awarded to

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

present in the Western world.Typical features that we

would readily find people wanting to correct in the

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

East. Nevertheless, those features are still a result of

the aging process, and identifying them is the purpose

of this chapter.

ARE ALL FEATURES OF AN AGED FACE

DUE TO THE AGING PROCESS?

As Fig. 2.1 demonstrates, a typical aged face will con-

sist of a myriad of features. However, further inspec-

tion reveals that these features can be divided into two

different categories. One category is chronological

aging alone.These are the features that are never seen

in youthful individuals, they occur as one ages, and

almost everyone who is aged has them. The second

2. Evaluation of the aging face

Philip J Miller

Aged features

Chronological features:

Those features thatappear in nearly all aged individuals, and are not present in the young

Morphological features:

Those features thatappear in nearly all aged individuals, but are also present in some youthful individuals

Fig.2.1 The breakdown of aged features into

chronological and morphological features.

02 Carniol-8028.qxd 8/23/2007 10:24 AM Page 11

category, I would like to refer to as morphological fea-

tures.These are features that, although possessed by all

aged people, are present in some individuals even in

their youth. Examples of these two categories are

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

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

crease or even a deepened nasolabial groove are pre-

sent in some 6-year-olds. These individuals are cer-

tainly not chronologically aged, nor do they appear to

appear old. Nevertheless, they certainly possess some

of the very features that we readily admit to appearing

in the aged face.

PATHOPHYSIOLOGY OF AGING

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

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

pathophysiological model of facial aging is in its

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

rise in our understanding of the pathophysiology of

facial aging over the next two decades. Prominent in

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

ume depletion as contributing to – if not primarily

responsible for – the ultimate contour irregularities

and transformations that occur in the aged face. The

old model of loss of elasticity, and sagging due to grav-

ity, will be replaced by a more detailed and compre-

hensive understanding of the individual role of and

complex interaction among

• skin aging

• skeletal remodeling

• fat pad atrophy

• subdermal fat loss

• fat deposition

Furthermore, we will find that these processes

inevitably exerts their effects on two anatomical com-

ponents that are fixed: the muscle attachments to the

bone and the osseocutaneous ligaments.This complex

reaction of changes and exertions is subject to gravita-

tional forces, resulting in a more typical aged facial

appearance. Adding to that an increase in muscle tone

in order to maintain facial function, particularly in the

periorbital region, so that decreased visual fields

are eliminated by contracting the frontalis, gives the

characteristic superficial skin findings associated with

the aged face.

YOUTH VERSUS BEAUTY

Where do we begin the aging facial analysis? Do we

start from the surface and proceed sequentially with

our assessment layer after layer? Do we begin at the

scalp and then proceed inferiorly towards the neck?

Do we start at the nasal tip and work posteriorly?

Do we make a global assessment and then work to the

specific areas? Does it matter?

I believe that the analytical algorithm that one uses is

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

patient is being compared. Thus, the real question in

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

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

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

youthful appearance or to an idealized youthful appear-

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


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

Aged features Youthful features It depends!!!!

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

• Malar depressions • Prominent cheeks • Low brows

• Furrows • Plump lips • Thin lip

• Skin excess • Smooth, unblemished skin • Nasojugal groove

• Actinic changes • Maxillary teeth visible • Nasolabial folds

• Mandibular teeth showing

• Submental fat accumulation


age, or to look more refreshed and rejuvenated, but

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

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

their appearance while maintaining their essential

features?

Here it is worthwhile to explore the concept of

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

aging face surgery that we perform. ‘Aging face

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

youthfulness alone that we are attempting to achieve.

Age does not necessarily make one less or more attrac-

tive – although it does play a role. Therefore, beauty

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

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

appearance, not a particular time period in the

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

cannot tell the patient’s age. One looks at the postop-

erative face (not compared with the preoperative face)

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

possesses volume and fullness.Their face is ageless. It

should be kept in mind that youth is not necessarily

attractive. If we were capable of magically restoring

our patients to their most desirable youthful state,

would they be completely satisfied? Some patients

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

‘aging face procedures’ means not only correcting an

aging face or features, but also aesthetic facial

features by which we are asked to alter their appear-

ance to make them more attractive.Therefore, ‘aging

face analysis’ may mean a collection of aged and not

necessarily aged features that the patient possesses to

make them more attractive and appear more youth-

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

without altering those characteristics that are essen-

tial to the person’s uniqueness – those essential fea-

tures that make us look undeniably who we are.These

features may consist of the slight slant of the palpe-

bral aperture, the position of the malar fat pad, the

dimple on the cheek, the cleft in the chin, or the full-

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

features have been routinely and erroneously thrown

in with the list of aging face features. Consequently,

we are quick to identify them as ‘aged’ and to eradi-

cate them or modify them in an effort to create an

idealized youthful appearance by removing all that is

considered aged.

Obviously, those features that are essential to one’s

uniqueness should not be tampered with.A wonderful

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

son has a very prominent upper eyelid crease, whereas

my daughter has a much fuller upper eyelid crease

with a lower brow.While typically a lower brow and

upper eyelid fullness is deemed to be a classic sign of

an aging face, requiring intervention, I submit that this

particular feature in my daughter is her ‘essence’ and

should not be at all manipulated now or 40 years from

now.We have seen this as well in two classical exam-

ples, one being Mr Robert Redford and the second

Mr Burt Reynolds. Both of their periorbital proce-

dures resulted in what would be considered a youthful

appearance. But their results occurred at the expense

of removing their essential upper eyelid features.Those

essential features for decades had been their ‘brand’;

a masculine hooded upperlid with a low brow.

Therefore, it is important to recognize that in per-

forming aging face analysis, one needs to separate the

analysis performed on a patient’s features that most

likely were a result of the aging process and those that

were never present at all and would in fact make this

individual appear perhaps more attractive. For the sake

of this chapter, we will focus exclusively on those fea-

tures that are a result of the chronological process.

Evaluation of the aging face 13

Fig.2.2 Twins with very different upper eyelid formations.

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

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

presented themselves in a 40-year-old.


SKIN

Among the absolute hallmarks of an aging face are the

changes associated with the skin. The most common

changes associated with facial skin aging are those due

to photoaging (skin damage related to chronic sun

exposure). This results in dyspigmented, wrinkled,

inelastic skin, with associated redness and dryness.

Furthermore, mild to moderate facial wrinkling and

laxity with benign and malignant lesions round out the

skin changes that should be addressed through many of

the techniques presented in this book. See Tables 2.2

and 2.3, which show the Fitzpatrick and Glogau classi-

fications of skin types and wrinkles respectively.

VOLUME LOSS

It is easy to overlook this particular component of facial

aging. Since surgical procedures reposition and lift, it is

only natural, but incorrectly, assumed that the cause of

that descent is skin laxity and gravity. However, on fur-

ther examination, evaluation, and analysis, it is clear that

descent and laxity can result from volume loss.As illus-

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

robust and lacks contour abnormalities. However, as

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

tial to not only descend, but also become deformed.The

difference between Figure 2.3(a) and 2.3(b) is nota gen-

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

inside the balloon. Reinflating the balloon, as opposed

to repositioning the tarp, is responsible for eliminating

all of those identifiable features.

Likewise, many of the features that we will discuss

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

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

the following areas: the temporal fossa, the lateral

brow, and the malar eminence. Furthermore, volume

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

it should be appreciated that overall loss of volume in


Table 2.2 Fitzpatrick skin types

Type Color Reaction to UVA Reaction to sun

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

fair skin, blue eyes tans; very fair skin tone

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

skin, blue or green eyes difficulty; fair skin tone

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

fair to medium skin tone

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

medium skin tone

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

black, Indian olive or dark skin tone

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

very dark skin tone

Table 2.3 Glogau wrinkle scale

Skin type Age (years) Findings

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

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

smile wrinkles

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

wrinkles at rest

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

generalized wrinkling


the subcutaneous tissue can make certain bony features

much more prominent along the infraorbital rim,

as well as the submandibular triangle, wherein the

submaxillary gland appears quite prominent.

CHIN POSITION

The next step in the facial analysis process is to assess

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

lower lip as well as the surrounding tissue. One should

look for the appearance of jowling, chin ptosis, chin

retrusion, submental fat accumulation and severe

neck skin laxity. Following the path of the mandible

posteriorly, the next assessment is the general protu-

berance and width of the angle of the mandible.

Atrophy and medial displacement of the angle of the

mandible or atrophy of the masseter muscle can in fact

contribute to a narrow and withdrawn facial contour.

The nasolabial lines are now assessed for their pres-

ence and degree, as well as for the contribution made

to these lines by ptotic skin and subcutaneous tissue

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

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

than to atrophy of the malar fat pad with resulting pto-

sis (see the balloon concept illustrated in Figure 2.3)

of the resulting subcutaneous tissue. Elevation of the

malar tissue superiorly and slightly posteriorly assesses

Evaluation of the aging face 15

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

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

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

a b


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

repositioning this tissue to efface the nasolabial line

and to reinflate the malar mound.

PERIORAL REGION

The lips are now evaluated for the prominence of the

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

maxillary teeth should be visible and the mandibular

teeth hidden.White lip wrinkles are also assessed.

PERIORBITAL REGION

Finally, attention is then directed towards the peri-

orbital region. Signs of upper lid ptosis are identified

and documented. Lower lid laxity and position are

identified and documented. Brow position is similarly

considered. Unlike the current trend of repositioning

the brow cephalically, I find that a lower placed brow

in both women and men, in combination with a more

robust lateral brow fullness, provides a sophisticated

and ageless appearance. An overly elevated brow does

not convey youth. It conveys surprise.The absence and

presence of forehead, glabellar, and periorbital rhytids

are evaluated and documented. Lower lid pseudo-

herniation of fat is noted, as is the presence of an infra-

orbital hollow. The degree of nasojugal depression is

documented, and photographs taken at an earlier age

are reviewed to ascertain which of the facial features

were present in youth and which were subsequently

acquired with aging.

SUMMARY

Technical expertise, however important to obtaining

excellent and consistent results, is only part of the

equation. The wrong technique performed flawlessly

will typically reveal a result that is below par, while

the correctly chosen procedure performed just satis-

factorily typically results in acceptable if not extra-

ordinary results. We can only recommend the most

suitable procedure if we perform a thorough and accu-

rate analysis, and that analysis includes not only an

assessment of the patient’s facial features, but also

their desires, expectations and their notions on which

procedures they feel most comfortable with to get

there.Therefore, proper and thorough analysis is para-

mount for it will lead us to selecting the most appro-

priate treatment plan and consequent results for any

individual patient and thus predictable and consistent

outcomes.

Nevertheless, analysis cannot be learned in a vac-

uum. Analysis inevitably requires that we compare it

with an idealized version, and even then it requires us

to understand the pathophysiology by which we got to

that point, and then we must correlate those findings

with a suitable treatment.

PLAN

Knowledge in all of these domains and re-exploring all

of these disciplines are essential parts of our growth as

physicians.



INTRODUCTION

Although skin resurfacing has been performed for

centuries in the forms of chemical peels, sanding, and

dermabrasion, it was not until the 1990s that lasers

were safely and effectively used as a resurfacing tool.

Initially, carbon dioxide (CO2) lasers with a wave-

length of 10 600 nm (1006 µm) were used as a

destructive tool. Technology advanced quickly in the

1990s from continuous-wave CO2

lasers to pulsed

CO2

lasers to help minimize the thermal damage

produced by the older CO2

lasers. Ultrashort pulse

technology emerged, as did computerized pattern

generator (CPG) scanning devices that allowed for a

more standardized delivery of the laser pulses.

Because of the prolonged healing required and the

risks associated with CO2

lasers, the erbium :yttrium

aluminum garnet lasers (Er:YAG) lasers with

stronger water absorption (2940 nm) and less ther-

mal damage were developed. Er:YAG lasers proved

to be excellent ablative tools, with shorter healing

times, but did not provide the same tightening that

was achievable with CO2

resurfacing. The next

advance came in the form of erbium lasers with

longer pulse widths that could provide more heating

and thermal damage in the skin. The short-pulsed

erbium lasers were combined with CO2

lasers and

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

fits of shorter healing times with more substantial

skin tightening.

Attempts to improve the laser resurfacing tech-

nique continue to be studied, with a concentrated

effort now looking at nonablative options to induce

dermal remodeling and fractionated skin resurfacing

to minimize the risks from skin ablation and to shorten

the healing times for patients.This chapter will focus

on ablative resurfacing, with an understanding that the

principles behind good patient selection and care will

remain paramount despite continued changes in the

lasers that might be developed.

INDICATIONS

The most common uses for laser skin resurfacing are

to treat wrinkles and acne scars of the face. Any epi-

dermal process should improve with laser resurfacing,

including lentigines, photoaging, actinic keratosis,

and seborrheic keratosis (Box 3.1). Some dermal

lesions, such a syringomas, trichoepitheliomas, and

angiofibromas, will improve with laser resurfacing,

but results will vary with the histologic depth of the

process. In our experience, there is a high recurrence

rate with dermal lesions. Actinically induced disease,

including actinic keratosis (AK) and actinic cheilitis,

can respond very well to laser resurfacing. Superficial

and nodular basal cell carcinomas have been success-

fully treated with the UltraPulse CO2

laser. The cure

rates achieved by Fitzpatrick’s group was 97% in

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

In

addition, the use of laser resurfacing may be used pro-

phylactically to reduce the risk for the development of

future AK and AK-related squamous cell carcinoma.2

Prevention of some basal cell carcinomas may be

achieved, although this has not been definitively

demonstrated.3

3. Carbon Dioxide Laser Resurfacing, Fractionated

Resurfacing and YSGG Resurfacing

Dee Anna Glaser, Natalie L Semchyshyn and Paul J Carniol


Box 3.1 Indications for laser skin resurfacing

• Photodamage

• Rhytids

• Acne scars

• Benign adenexal tumors

• Benign epidermal growths

• Rhinophyma

• Actinic cheilitis

• Actinic keratosis

• Basal cell carcinoma

• Scar revision

Despite the multiple uses, by far the prime use in

our office is for the improvement of facial photoaging,

rhytids, and acne scars.To date, ablative laser resurfac-

ing is the most efficacious technique we have to treat

perioral rhytids (Fig. 3.1).

PATIENT SELECTION

The key to successful laser resurfacing is proper

patient selection (Table 3.1). Potential candidates

need to have a realistic expectation of the outcome,

risks, and significant amount of time required to heal,

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

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

poor wound healing, and is comfortable with wearing

make-up during the postoperative healing period.The

history should specifically address issues that relate to

wound healing, such as immunodeficiency, collagen

vascular diseases, anemia, diet, scarring history,

keloid formation, recent isotretinoin usage, and past

radiation therapy to the area. The history should

include the patient’s general health, current or past

medications, and mental health issues. Diseases

known to koebnerize are also a relative contraindica-

tion – these include psoriasis, vitiligo, and lichen

planus. Diseases that reduce the number of adenexal

glands or alter their function are relative contraindi-

cations and need to be reviewed – these include colla-

gen vascular diseases such as systemic lupus

erythematosus and scleroderma. A history of herpes,

frequent bacterial infections, or frequent vaginal

candidiasis is not a contraindication, but should be

noted to better plan how to treat the patient during

the perioperative period.

Equally important is to ascertain the pigment

response of the patient (in terms of hyperpigmenta-

tion or hypopigmentation) to sun exposure or injuries.

In our experience, patients with Fitzpatrick skin type

IV are some of the most challenging to treat due to

their risks of postoperative dyschromias. Patients will

need to avoid sun exposure for several months after

the surgery, and the physician needs to document the

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

broad-spectrum sunscreens daily. In the Midwest of

the USA, with four distinct seasons, it is preferable

to perform deep resurfacing procedures during the

winter months to minimize sun exposure. However, a

thorough review of a patient’s travel plans during the

3- to 4-month healing period then becomes impor-

tant. Although most patients recognize the risks of a

trip to a warm sunny destination, many may under-

estimate the risks with higher altitudes such as with

snow skiing.


Fig.3.1 Significant reduction in perioral rhytids

at 4 months.

a

b


PROCEDURE

Preoperative care

The preoperative care should begin at the time that the

patient decides to undergo laser skin resurfacing.

Photoprotection and prevention of tanned skin should

be maximized before surgery. Melanocyte stimulation

before the laser resurfacing may increase the risk of

postinflammatory hyperpigmentation after the proce-

dure.A sunscreen with a sun protection factor (SPF) of

30 or higher should be used daily, along with an ultra-

violet A (UVA) blocker such as zinc oxide, titanium

dioxide, or avobenzone.We advise patients to supple-

ment sunscreen use with physical measures such as

large sunglasses and hats.

The use of topical therapy before surgery is com-

mon – this might include topical tretinoin, hydro-

quinone and antioxidants. It is clear that the use of a

topical retinoid is quite valuable before skin resurfac-

ing with chemical peels through its action on the

stratum corneum and epidermis. The use of topical

tretinoin can increase the penetration of the peel, pro-

vide a more even peel and enhance healing.4,5

Due to

the high affinity for water with the CO2

and Er:YAG

lasers, these lasers are very capable of evaporating the

epidermis without the use of tretinoin.There may be

other effects that could theoretically improve the laser

resurfacing process and healing. Retinoids regulate

gene transcription and affect activities such as cellular

differentiation and proliferation. They can induce

vascular changes of the skin and a reduction and

redistribution of epidermal melanin.6

Retinoids (at

least theoretically) can speed healing and perhaps

reduce pigmentary changes.Thus, it is our practice to

begin a topical retinoid at least 2 weeks prior to the

procedure – even earlier if possible.

Because of the relatively common development of

postinflammatory hyperpigmentation after laser resur-

facing, especially in the darker skin tones, many physi-

cians will pretreat with a bleaching agent such as

hydroquinone (HQ). HQ works by inhibiting the

enzyme tyrosinase, which is necessary for melanin

production within the epidermis. It can also inhibit the

formation of melanosomes. There is a clear role for

HQ products after laser resurfacing to treat hyperpig-

mentations; this will be discussed later in the chapter.

HQ may not have any clinical effect when used prior

to laser surgery, since the melanocytes that it is work-

ing on are all removed during the laser procedure. It is

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

cream for those patients at high risk for developing

hyperpigmentation after their procedure. Like the

topical retinoids, it can be irritating and should be dis-

continued if it is causing an irritant dermatitis. A rare

side-effect of HQ is exogenous ochronosis, but this

usually occurs only with prolonged use of higher con-

centrations and should not develop even in predis-

posed individuals within just a couple of weeks.7

There is no proven role for the use of topical anti-

oxidants, alpha-hydroxy acids, or beta-hydroxy acids,

but they are often in the skin care regimen of patients

and we do not discontinue their use prior to laser

resurfacing.

Tobacco smoking can delay wound healing, and

patients are strongly encouraged to stop tobacco

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

ing to stop smoking at least 2 weeks prior to the

Carbon dioxide laser resurfacing, fractionated resurfacing and YSGG resurfacing 19

Table 3.1 Patient selection

Absolute contraindications Relative contraindications

Unrealistic expectations Tendency to keloid formation

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

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

History of collagen vascular disease

History of vitiligo

Diseases that koebnerize (e.g., psoriasis)

Pregnancy/breastfeeding

Unable/unwilling to avoid sun exposure postoperatively


procedure, he or she is encouraged to switch to a

tobaccoless product such as a patch or gum.

The use of oral antiviral therapy is standard practice,

even if the patient does not have a history of herpes

simplex virus (HSV) infections. Typically, famciclovir

or valacyclovir is used in prophylactic doses such as

famciclovir 250 mg twice daily or valacyclovir 500 mg

twice daily. Doses need to be adjusted for renal dys-

function.The patient begins therapy the day before the

procedure and continues until re-epithelialization

is complete. It can be helpful to keep antiviral therapy

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

forgot to initiate therapy before the procedure.

The use of prophylactic systemic antibiotics is of

questionable value prior to surgery and remains con-

troversial.8A first-generation cephalosporin is typically

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

tinely used by the other (DAG). Interestingly, recent

animal studies have shown that CO2

laser resurfacing

reduces microbial counts of most microorganisms on

lasered skin compared with skin treated using mechan-

ical abrasion.9

On the other hand, nasal mupricin is

routinely prescribed (by DAG) for healthcare workers

due to the current high rates of methicillin-resistant

Staphylcoccus aureus (MRSA) in hospitals and nursing

homes. Unfortunately, the incidence of MRSA in the

community is also increasing, and MRSA may be

encountered in non-healthcare workers.10,11

Surgeons

should monitor their local communities for recom-

mendations regarding community-acquired MRSA.

There have been no published studies on the use of

antifungal therapy prior to laser resurfacing, although

Candida infections can develop during the postopera-

tive period, especially when occlusive dressings are

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

treat women with a known history or frequent or

recurrent vaginal candidiasis with oral fluconazole

after the procedure, even when using open healing

techniques.9

Botulinum toxin is routinely administered to our

patients prior to laser resurfacing of the face. Placebo-

controlled studies have demonstrated improved results

when compared with laser resurfacing alone.12,13

Pre-

operative use of botulinum toxin type A can diminish

rhytids as well as textural, pigmentational and other

features of skin aging when used in conjunction with

laser resurfacing.13

Our preference is to treat at least 2

weeks prior to laser surgery and repeat at approxi-

mately 3 months postoperatively.

Patients are given instruction sheets listing skincare

items they will need after the procedure along with

their prescriptions for postcare medications. These

will be discussed later in the chapter.

Laser resurfacing

Before coming into the office for their procedures,

patients are instructed to wash their face well. After

drying, they apply a topical anesthetic cream such as

EMLA (a eutectic mixture of lidocaine 2.5% and

prilocaine 2.5%) under occlusion with a plastic wrap.

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

will reapply the topical anesthetic 45 minutes prior to

the procedure. The EMLA not only helps to provide

cutaneous anesthesia, but also hydrates the skin, which

decreases the procedure’s side-effect profile.14

Further

anesthesia or analgesia can be obtained with nerve

blocks, local infiltration of lidocaine, tumescent anes-

thesia or diazepam, and, in our office, intramuscular

meperidine and midazolam, or ketorolac, is used.The

topical agents are removed prior to beginning the laser

procedure.

When using the UltraPulse CO2

laser (Lumenis,

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

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

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

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

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

sity should be decreased to 6 and then 5 when feather-

ing to the hairline and jawline. The first pass is

intended to remove the epidermis, which is wiped free

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

second pass is performed to central facial areas at a

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

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

performed at a density of 4. Energies are decreased

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

needed in areas of acne scarring or in the perioral

area with deeper wrinkles. As with any laser proce-

dure, careful monitoring of tissue response during

treatment is performed to determine the necessity of

any additional passes and energy level used.



A similar approach is taken when using one of the

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

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

mis and frequently 25 J/cm2

(100 µm ablation, zero

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

third pass is used to heat and hopefully to induce skin

tightening. Ablative and coagulative settings are used

with a typical second, pass and a commonly used set-

ting would have 50% overlap with 10 µm ablation and

80 µm coagulation.

Where there are very deep rhytids or scars, the

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

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

remember that when used in the ablative mode, there

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

can help identify the depth of resurfacing.

Laser resurfacing is best done to the entire face

to avoid lines of demarcation between treated and

untreated skin.The procedure should be carried into

the hairline and at the jaw and chin; a feathering tech-

nique should be used. This includes a zone of

decreased energy, decreased density, or pulse over-

lap.When treating a patient with moderate to severe

photodamage, it is important to blend into the neck

as much as possible. One approach is to lightly resur-

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

Jessners and/or glycolic acid peel is used. Another

option is to laser the neck, which will be reviewed

later in the chapter.

Postoperative care

Wound care is critical, and regimens vary among

physicians. Occlusive and nonocclusive dressings are

available. Occlusive dressings cover the skin and are

usually removed in 1–3 days. These can decrease

patient discomfort, but may promote infection by har-

boring bacteria or yeast.When opaque, the dressings

can mask visualization of the wound, thus delaying the

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

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

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

commonly removed on the second day postoperatively

and the patient is switched to open healing.

Open dressings or nonocclusive dressings are usu-

ally petroleum-based ointments. Frequent soaking and

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

by frequent application of petroleum jelly, Aquaphor

ointment or one of the many wound care ointments

that are available. Additives, fragrances, or dyes will

increase the chance of contact allergic or irritant der-

matitis developing and should be limited as much as

possible. In very sensitive individuals, pure vegetable

shortening can be used. Dilute vinegar can be used to

soak and debride the wound, promote healing, and

inhibit bacterial growth.

Wound care needs to be performed until re-

epithelialization is complete. Depending on the type of

laser used and how aggressive the surgeon was with his

or her settings, re-epithelialization should be complete

within 5–10 days. Prolonged healing times can

indicate an infection, contact dermatitis, or other

problem, and increases the risks of complications.

COMPLICATIONS AND THEIR

MANAGEMENT

Complications following laser surgery are relatively

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

treated quickly and efficiently to minimize patient

anxiety and long-term morbidity.15

Obviously, good

patient selection, surgical management, and postoper-

ative care are necessary to help prevent complications,

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

(Box 3.2).

Box 3.2 Complications of ablative laser resurfacing

• Activation of herpes simplex virus (HSV)

• Bacterial infection

• Candidal infection

• Delayed healing

• Prolonged erythema

• Hyperpigmentation

• Hypopigmentation

• Acne

• Milia formation

• Contact dermatitis

• Scarring

• Line of demarcation with untreated skin



The most common complications seen immediately

postoperatively are swelling and exudative weeping

related to the degree of wounding. If facial swelling

is severe, oral or intramuscular steroids, and non

steroidal anti-inflammatory agents (NSAIDs) can be

administered. Milia formation is common, with the

development of small white papules, usually < 1mm

in size, which need to be distinguished from pustules.

Papules are an occlusive phenomenon, and will

resolve without treatment.

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

fungal in nature (Table 3.2).16

Signs and symptoms

include pain, redness, pruritus, drainage (usually not

clear), yellow crusting, and sometimes erosions, vesi-

cles or pustules may develop (Fig. 3.2). Pruritus, espe-

cially, should alert the physician to a possible infection.

Appropriate evaluation may include tzanck smear,

potassium hydroxide (KOH) prep, gram stain, and

cultures to accurately diagnose the causative agent.

Treatment should begin early, pending culture results.

Fitzpatrick’s group found that half of their patients

who developed a post-laser infection had more than

one microorganism. Thus, broad coverage should be

initiated, and should generally include an agent that

will cover Pseudomonas aeruginosa.

Acne is another complications that can be seen rela-

tively early in the course. Oral antibiotic therapy and

discontinuation of petroleum-based ointments usually

suffice. Topical acne therapies are not generally well

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

judiciously.

Contact dermatitis can occur, and may be due to an

allergic reaction or an irritant reaction. It may occur

within the first few weeks or months after laser resur-

facing. Redness, pruritus, and delayed healing may be

noted, but vesiculation is rare. Topical antibiotics are

a common cause of allergic contact dermatitis, and

should be avoided. Patients may be using them without

the knowledge of their physician. Topically applied

agents should be reviewed and discontinued. Dyes and

fragrances that are added to laundry detergents, fabric

softeners, and skincare items are also potential causes.

Discontinuation of the offending agent(s) and topical

corticosteroids should be initiated early.17


Table 3.2 Causative agents encountered in CO2

laser

infections16

Organism Percent

Pseudomonas 41.2

Staphylococcus aureus 35.3

S. epidermidis 35.3

Candida 23.5

Enterobacter 11.8

Escherichia coli 5.9

Proteus 5.9

Corynebacterium 5.9

Serratia 5.9

Herpes simplex virus (HSV) 5.9

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

edema,yellow drainage and crusting,and pustules.The

patient noted increasing discomfort and pruritus.

a

b


PIGMENTARY ABNORMALITIES

Hypopigmentation

Lightening of the skin is desirable for most patients

undergoing facial rejuvenation. Patients who undergo

resurfacing of cosmetic units such as the perioral area or

periocular area may exhibit a noticeable difference

between the ‘new’ treated skin and the untreated skin

that exhibits the various dyschromias associated with

photoaging.This should be avoided as indicated previ-

ously, but when faced with such a patient, treating the

remaining skin will lighten the hyperpigmentation and

help to blend in the differences.Although topical agents

such as retinoids and hydroquinones can be used, visible

results take months and are not practical for most

patients. Resurfacing is the fastest way to improve

patients’ appearance in these cases. Depending on the

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

trichloroacetic acid (TCA) peel may be sufficient, or

laser resurfacing can be performed. Superficial resurfac-

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

is an excellent device.The goal is to remove the epider-

mis, and one or two passes maybe all that is required.

This heals rapidly and with minimum risks.

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

to find a good stopping point. In these instances, treat-

ing the full face may only accentuate the discoloration

of the neck. Light rejuvenation of the neck can be

done, but may accentuate the damage to the chest.

Light resurfacing can be performed down the neck and

chest area, extending onto the breast – but this may

then accentuate the damage to the arms and forearms,

etc. In these patients, a combination of modalities can

be used: topical agents as described above for the

entire area; laser resurfacing of the face; lighter resur-

facing of the neck and chest (we generally use chemi-

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

but Er:YAG laser resurfacing is used successfully by

many physicians); and chemical resurfacing of the

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

glycolic acid.

Another option is the use of nonablative laser tech-

nology such as the ‘Photofacial’ technique. Several

intense pulsed light (IPL) systems are now available,

which use a broad-spectrum intense pulsed light

source with changeable crystals attached to the hand-

piece to filter out undesirable wavelengths. This

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

upper extremities. Numerous treatment sessions are

required, but are generally well tolerated, with little

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

with skin type and area, but the neck is generally

treated more conservatively and using lower fluences.

It is important that the operator carefully place the fil-

ters to avoid overlapping and also to prevent skipped

areas or ‘footprinting’.

Depigmentation

True depigmentation of the skin following laser resur-

facing is more difficult to treat than the pseudohypo-

pigmentation described above. The skin acquires a

whitish coloration and does not flush or change color

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

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

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

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

sents superficial scarring or fibrosis. It can occur after

any form of resurfacing, but it is more commonly

encountered with CO2

laser resurfacing and is much

less common with Er : YAG resurfacing. Like pseudo-

hypopigmentation, depigmentation seems to be more


Fig.3.3 Persistent depigmentation 2½ years

following CO2

laser resurfacing that was performed in the

perioral area only.


evident when cosmetic units are treated individually

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

more aggressively than the surrounding skin.

Depigmentation has been considered a permanent

complication of CO2

laser resurfacing.When evaluated

histologically, there is a varying quantity of epidermal

melanin present. Residual epidermal melanocytes are

present, indicating that repigmentation should be pos-

sible. Mild perivascular inflammation has been noted

in 50% of biopsies, and superficial dermal fibrosis was

present in all biopsies.18

This suggests that the patho-

genesis of the laser-induced hypopigmentation may be

related to a suppression of melanogenesis and not

complete destruction of the melanocytes.

Grimes et al18

have reported successful treatment of

hypopigmentation following CO2

laser resurfacing

using topical photochemotherapy twice weekly.18

Seven

patients were treated with topical 8-methoxpsoralen

(0.001%) in conjunction with UVA therapy. Moderate

to excellent repigmentation was demonstrated in 71%

of the patients. Using the same reasoning, narrowband

UVB and an eximer laser may both be effective.

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

been reported to be efficacious for vitiligo, while

excimer lasers emit at 308 nm and can be targeted

to a given site.19

Alexiades-Armenakas et al20

have

reported two patients who were treated for laser-

induced leukoderma using an excimer laser. They

speculate that repigmentation is related to the stimu-

lation of melanocyte proliferation and migration,

along with the release of cytokines and inflammatory

mediators in the skin.

Potential disadvantages of any of these therapies,

however, include the time necessary to see repigmenta-

tion, cost, erythema and pruritus during therapy, and

hyperpigmentation of skin immediately surrounding

the treated skin, which can take months to return to

normal. Unfortunately, the results are mixed, and

return to baseline can occur after therapy is discontin-

ued. Repigmentation has been an unrealistic goal, and

until more data are available on investigative tools such

as phototherapy, an honest discussion must take place

with the patient. Additional resurfacing of the unaf-

fected skin may be helpful to reduce any hyper pigmen-

tation or dyschromia if present, but will only help to

reduce the differences with adjacent areas. Once again,

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

Scarring

The development of scarring following laser surgery is

perhaps the most feared and distressing complication

encountered. Deeper wounds are more likely to result

in scarring, which is not usually encountered unless

the wound extends into the reticular dermis.

However, since this is the level that is generally tar-

geted with the CO2

laser to eradicate wrinkles, acne

scars, and varicella scars, cosmetic surgeons will be

faced with scarring if they perform enough proce-

dures. Hypertrophic scars can develop anywhere, but

are most likely to occur around the mouth, chin,

mandibular margin, and less often over other bony

prominences such as the malar and forehead regions.

Nonfacial skin is also more likely to develop scarring

due to the relative paucity of pilosebaceous units and

adenexal structures. It has been the experience of one

of us (DAG) that patients with a history of acne scar-

ring, regardless of prior isotretinoin use, are more

likely to develop delayed wound healing and hyper-

trophic scarring when compared with the average

patient.

The surgeon should be alerted to possible scarring

when there is delayed wound healing for any reason.

Infections need to be treated early and aggressively.

Candidal, bacterial, and herpetic infections can delay

healing, prolong the inflammatory stage, and increase

the chance that the wound will heal with scar develop-

ment. Likewise, contact dermatitis that is not con-

trolled early and poor wound care are potential

precursors for postoperative scarring.

Early on, the treated skin may appear redder than

the surrounding skin. As the process continues, tex-

tural changes can be discerned with palpation of the

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

will develop. In the early stages, topical steroids may

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

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

concern and not to the entire lasered area. If pro-

longed erythema alone is noted without any dis-

cernible textural changes, a class II or III steroid may

suffice but if thickening or induration is present, a class

I steroid should be considered.The patient needs to be

monitored closely so that steroid-induced atrophy,

stria, or telangectasia do not develop and so that

progression of the scarring can be followed.



Intralesional glucocorticosteroids are probably

more effective than topical steroids if textural changes

and induration have developed.We typically use triam-

cinolone acetonide diluted to a concentration of 2.5–5

mg/cm3

for facial scars, but will use 7.5–10 mg/cm3

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

used to minimize further trauma to the area, and the

injection is given into the superficial dermis of the

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

depending on the response or progression of the scar.

Treatment should be continued until the skin returns

to the same texture and consistency as the surrounding

tissue. Overtreatment can result in atrophy, and

telangectasia can develop.

Some surgeons use occlusion therapy in the early

stages of scarring. A very large number of silicone gel

dressings have become available over the past few

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

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

A mild dishwashing detergent can be used to clean the

dressing. An onion skin extract, Menderma gel (Merz

Pharmaceuticals, Greensboro, NC), is also marketed

to improve and prevent scarring. Its efficacy in not

known, and patients using any such product need to

be monitored for irritant and allergic contact

dermatitis.

Another treatment used after laser surgery to treat

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

This antimetabolite is

a pyrimidine analog and works by inhibiting fibroblast

proliferation. A concentration of 50 mg/cm3

is

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

used each injection session. Although effective, the

injections are quite painful. The addition of Kenalog

should be considered and is mixed such that 0.1 cm3 of

Kenalog 10 mg/cm3

is added to 0.9 cm3

of the 5-FU

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

efficacy are associated with the latter solution.

Approximately 0.05cm3

is injected per site, separated

by approximately 1 cm. Injections should be per-

formed two or three times weekly initially, and only

the indurated portions of the scar should be injected.

Side-effects include pain with injection, purpura, and

rarely superficial tissue slough.

Flashlamp-pumped dye laser (FLPDL) therapy is

effective, and was first described by Alster.22

The

settings typically used with the 585 nm FLPDL are

5–7.5 J/cm2

with a 7 mm spot size or 4–5J/cm2

with

a 10 mm spot size. Newer vascular lasers and intense

pulsed light sources are also being used to treat surgi-

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

has a wavelength of 595 nm and a cryogen spray to

help cool the epidermis is our preferred laser for

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

VascuLight (Lumenis, Santa Clara, CA) has been effec-

tive with a 570 nm filter.Treatments are administered

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

minimum of 2–4 treatment sessions.

Patients may develop anxiety about having ‘more

laser surgery’ if they have already developed a scar

from previous laser surgery, but these techniques are

generally well tolerated and with minimal risks.

Because of the low fluences used, purpura generally

does not develop. Although well accepted as an effec-

tive treatment, not all studies have demonstrated good

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

by Wittenber et al,23

the flashlamp pulsed dye laser and

silicone gel sheeting showed improvement in scar


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

6 months post CO2

laser resurfacing. (b) Scar development

present at the lip 6 months post CO2

laser resurfacing.

b

a


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

no different than the controls.

Combining modalities will ensure the best results in

reduction of scar volume and erythema and improve-

ment of texture. Laser therapy can be added to the

regimen after the scar has begun to show flattening

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

pressed by 5-FU, inflammation is suppressed by corti-

costeroids, and pulsed dye laser suppresses angiogenesis

and endothelial cell growth factors.

Concomitant use of the CO2

laser and the pulsed

dye laser has been described for nonerythematous

scars.24

The CO2

laser is used to de-epithelialize the

scar; total vaporization of the scar is not suggested.

Then the 585nm pulsed dye laser is used with fluences

of 6–6.5 J/cm2

with a 7 mm spot.

Finally, resurfacing can be tried for scars that have

not responded to the treatment modalities already

described. This, however, can result in further scar-

ring, and should be used judiciously.The patient needs

to be counseled extensively regarding the potential

risks.The scarred area and a small amount of normal

appearing skin surrounding the scar should be anes-

thetized with local anesthesia. Either a CO2

Er:YAG

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

since it provides ablation with little thermal injury.The

scarred area should be ablated superficially with an

additional pass to blend with the surrounding skin.

Wound care is performed in the standard fashion.

Less commonly, hypertrophic scars are hyperpig-

mented. In these cases, either a pulsed dye laser or

a pigment-specific pulsed dye 510 nm laser and a

532 nm frequency-doubled neodymium (Nd):YAG

laser can be used to lighten the scar. The immediate

endpoint is the production of an immediate ash-white

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

achieved in approximately 75% of scars.25

SPECIAL CONSIDERATIONS

Resurfacing cosmetic units

For patients who are not willing to undergo entire face

resurfacing and who have deep rhytids limited to the

perioral area, CO2

laser resurfacing can be combined

with more superficial resurfacing. The preoperative

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

peeled to the desired depth. When using chemical

peeling, the face is first degreased with alcohol or ace-

tone. Jessner’s peel is applied and then TCA is applied

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

depending on the desired results. Application of the

TCA is performed one cosmetic unit at a time to

decrease discomfort and to monitor for the desired

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

enhance the patient’s comfort. Once the peel or

superficial laser resurfacing has been performed, the

perioral area can be treated with the more aggressive

CO2

or Er:YAG lasers as described above.The peeled

skin will be red and clearly identifiable to the laser sur-

geon.Wound care is the same as previously described.

Due to the smaller surface area that is more deeply

treated, there is less total swelling and exudative

drainage. This approach is especially popular in our

patients who are ready to undergo a second resurfac-

ing procedure for the mouth area but have retained

satisfactory results to the rest of their face.

Neck resurfacing

Due to the relative paucity of adenexal structures in

the neck, rejuvenation procedures need to be performed

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

photoaging was established in the late 1990s, but only

modest improvements were seen.26

The desire to

improve results led to the use of the CO2

laser, but

with mixed results. In 2001, Fitzpatrick and Goldman27

published a study on 10 subjects using the UltraPulse

CO2

laser. Despite no complications being seen at the

initial neck test areas, 40% of the patients had compli-

cations observed at 3–6 months, including patchy

hypopigmented scarring (with and without textural

changes) in the lower portions of the neck. Despite

some obvious improvements noted in the color

and texture of the skin (although no improvement in

wrinkling was observed), it was concluded that the

risks outweighed the potential benefits, at least at the

three different parameters studied. In 2006, Kilmer

et al28

reported their experience in performing CO2

neck resurfacing in over 1500 patients. Only 2 patients

developed hypopigmentation. Over 99% of the neck

cases in this study were treated concomitantly with

facial resurfacing. Any patient who had undergone



prior neck radiation was excluded from neck CO2

resurfacing. Topical EMLA was used as previously

described in this chapter with a second application 45

minutes before the procedure. Lower energy densities

were used as the treatment proceeded down the neck.

Epidermal debris was not wiped off the neck, in order

to minimize additional trauma.

Fractional CO2

resurfacing

Carbon dioxide laser resurfacing can give the most

dramatic improvements, in terms of smoothing skin,

decreasing rhytids, removing lentigines and tightening

facial skin. However, due to the typical associated

length of recovery it remains unpopular with patients.

Other lasers have been developed to try to achieve a

more carbon dioxide laser resurfacing type of

improvement with a relatively brief recovery period.

One of these is fractional CO2

laser resurfacing and the

other is the new YSGG resurfacing laser.

Although fractional lasers are now available in sev-

eral different wavelengths, the fractional 10 600 nm

carbon dioxide laser can offer some of the beneficial

ablative and tightening effects associated with tradi-

tional Carbon dioxide laser resurfacing.

In fractional photothermolysis, a fraction of the skin

surface is treated with the laser, resulting in small

zones of thermal injury bridged by surrounding areas

of untreated skin.29

Since, only a fraction of the skin is treated, re-

epithelialization occurs relatively quickly by migration

of epithelial elements from the adjacent untreated

skin, into the lasered areas.

The fractional CO2

laser (Active Fx, Lumenis, Inc.,

Santa Clara, CA, USA), produces small spots (approx-

imately 1.3 mm) that are scanned using the computer-

ized pattern generator. Between the spots there are

areas of untreated skin.

This laser is designed to decrease the possible lateral

thermal effects of the laser, while allowing the deeper

thermal heating effects in each of the treated areas for

stimulation of neocollagen production and inducing

skin contraction.

Since the laser treatment is fractionated the lateral

heating effects are decreased by leaving adjacent

untreated areas which allow for heat dissipation.

Furthermore the device’s CoolScanTM

setting allows

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

skips from one region to the next rather than treating

sequential adjacent areas. This allows for additional

thermal relaxation between pulses resulting in less

overall thermal injury, and quicker recovery. Post-

treatment erythema resolves more rapidly.

The treated areas are smaller and placed in a less

dense manner than in traditional CO2

laser resurfac-

ing. Settings are variable and are based on patient need

in terms of acceptable downtime and degree of photo-

damage or acne scarring.

Initially, post treatment patients develop area of punc-

tate crusting surrounded by areas of unlasered skin. As

could be anticipated this also becomes pink and devel-

ops mild swelling. Typically, the third author has the

patients keep the area moist until it completely re-

epithelializing.This can be achieved by application of

Aquaphor (Beiersdorf,) every 8 hours or other dress-

ings with a moisturizing effect.The third author also

routinely gives antivirals starting twenty four hours

prior to the laser treatment. Each physician, must

decide in their own prophylaxis and after care regimens.

Typically patients can resume their regular activities

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

as dramatic as with traditional carbon dioxide laser

resurfacing the third author’s patients have been

pleased with the results of these treatments.They have

noted improvement in their skin texture, wrinkles,

and lentigines as well as some mild skin tightening.

More aggressive settings can also be used for more

dramatic results dramatic results with a consequent

increase in patient downtime. Patients with deep

rhytids and significant skin laxity who are willing to

deal with the healing process associated with CO2

resurfacing can have a non-fractionated resurfacing.

A different type of fractional CO2

laser is currently

under development (Reliant Technologies, Mountain

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

deeply than the traditional CO2

laser and may allow a

greater tightening effect. (presented at American

Society of Dermatologic Surgery Annual meeting,

palm Desert, CA, October 2006)

Another alternative to fractional CO2

resurfacing is

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

California.) This laser is designed to resurface similar

to an erbium laser but to provide deeper associated

thermal effects to create greater collagen stimulation



and skin tightening.The effect is between the effect of

the typical erbium laser and the carbon dioxide laser. It

is used to improve skin smoothness, reduce mild wrin-

kles and decrease hyperpigmentation.

THE FUTURE

Fractional laser, contiguous laser and plasmakinetic

resurfacing will undoubtedly continue to advance and

improve. Further improvements in patient outcomes

may be obtainable with combination therapy including

using nonablative lasers, fillers, neurotoxins, and cos-

meceuticals.The push continues for less invasive, more

efficacious tools with added predictability and safety.

The key is to a successful resurfacing practice hower,

still involves proper patient selection, good technique

and wound care, and the early identification and man-

agement of complications.

REFERENCES

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

Treatment of basal cell carcinoma with the pulsed carbon

dioxide laser: a retrospective analysis. Dermatol Surg

2004;30:1214–18.

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

Full face laser resurfacing: therapy and prophylaxis for

actinic keratoses and non-melanoma skin cancer. Lasers

Surg Med 2004;34:114–19.

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

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

Berlin: Springer-Verlag 2005:83–98.

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

healing after trichloroacetic acid chemical peel. Arch

Dermatol 1991;127:678–82.

5. Vagotis FL, Brundage SR. Histologic study of dermabra-

sion and chemical peel in an animal model after pretreat-

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

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

the treatment of facial photodamage. Arch Dermatol

2001;137:1597–604.

7. Penneys NS. Ochronosis-like pigmentation from hydro-

quinone bleaching creams. Arch Dermatol 1985;

121:1239–49.

8. Nester MS. Prophylaxis for and treatment of uncompli-

cated skin and skin structure infections in laser and

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

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

effect of carbon dioxide laser skin resurfacing and

mechanical abrasion on the skin’s microbial flora in an

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

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

of the changing epidemiology of methicillin-resistant

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

11. Fritsche TR, Jones RN. Importance of understanding

pharmacokinetic/pharmacodynamic principles in the

emergence of resistances, including community-associated

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

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

linum toxin pretreatment on laser resurfacing results: a

prospective, randomized, blinded trial. Arch Facial Plast

Surg 2001;3:165–9.

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

movement-associated rhytides following CO2

laser resur-

facing. Dermatol Surg 1999;25:259–61.

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

laser resurfacing using supplemented topical anesthesia

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

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

SL, McDaniel DH. The incidence of adverse healing

reactions occurring with UltraPulse CO2

resurfacing

during a multicenter study. Lasers Surg Med 1996;

Suppl 8:S34.

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

SR. Infections complicating pulsed carbon dioxide laser

resurfacing for photoaged facial skin. Dermatol Surg

1997;23:527–35.

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

Dermatol Ther 2005;18:227–41.

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

resurfacing-induced hypopigmentation: histologic alter-

ations and repigmentation with topical photochemother-

apy. Dermatol Surg 2001; 27:515–20.

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

xenon-chloride excimer laser and narrow-band ultravio-

let B in the treatment of vitiligo: a comparative study.

J Kor Med Sci 2005;20:273–8.

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

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

excimer laser for pigment correction of hypopigmented

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

21. Fitzpatrick R. Treatment of inflamed hypertrophic scars

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

22. Alster T. Improvement of erythematous and hypertrophic

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

Ann Plast Surg 1994;32:186–90.

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

single-blind, randomized, controlled study to assess the

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



laser and silicone gel sheeting in hypertrophic scar treat-

ment.Arch Dermatol 1999;135:1049–55.

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

comparison of CO2

laser vaporization with and without

simultaneous pulsed dye laser treatment. Dermatol Surg

1998;24:1299–302.

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

mented hypertrophic scars with the 585 nm pulsed dye

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

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

tive study. Dermatol Surg 2002;28:714–19.

26. Goldman MP, Fitzpatrick RE, Manuskiatti W. Laser resur-

facing of the neck with the erbium : YAG laser. Dermatol

Surg 1999;25:736–7.

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

Resurfacing of photodamaged skin on the neck with

an UltraPulse carbon dioxide laser. Lasers Surg Med

2001;28:145–9.

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

effective carbon dioxide laser skin resurfacing of the

neck. Lasers Surg Med 2006;38:653–7.

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

Fractional photothermolysis: a new concept for cuta-

neous remodeling using microscopic patterns of thermal

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

30. American Society of Dermatologic Surgery Annual

Meeting, Palor Desert, CA, October 2006.



MODALITIES OF SKIN REJUVENATION

Aesthetic skin rejuvenation (ASR) is certainly not a

new process, and historical accounts date back as many

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

humans (both male and female) have been utilizing

treatments to improve the appearance of a poor com-

plexion or to enhance the beauty of a natural complex-

ion. Throughout the ages, humans have sought out

simple, elective cosmetic methods to improve highly

visible and undesirable permanent cutaneous signs:

facial wrinkles and residual facial scars that may follow

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

first examples of such ‘treatments’ were apparently

noted in ancient Egypt and recorded in the famous

Edwin Smith Surgical Papyrus, the oldest medical doc-

ument in existence.2The description of the wrinkle-

removal recipe prepared from hemayet fruit included

the composition and the technique for application.

Ancient Greece and the Roman Empire are both well

represented in the quest for more beautiful skin, and

Cleopatra (whose name has been synonymous with

beauty through the ages) wrote a book on beautifica-

tion that was quoted by Galen and other medical writ-

ers. Her recipes were quoted well into the Middle

Ages. Due to the lack of sophisticated medical technol-

ogy, many of these treatments relied on what we would

now call homeopathic ‘spa’ products and abrasives.

The transition to utilizing chemicals for ASR occurred

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

1842 by the French chemist August Laurent and pre-

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

also found Hebra3

utilizing various acids, alkalis, and

other corrosives to treat freckles and melasma. It is not

clear whether Hebra treated wrinkles with these chemi-

cal agents. Chemical agents facilitating ASR (particularly

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

and George Miller MacKee4

became a proponent of

chemical ASR after first experimenting on himself.

In 1953, Abner Kurtin5

published ‘Corrective surgi-

cal planing of the skin’, capturing the imagination of

plastic surgeons and dermatologists. He proposed der-

mabrasion as a better method to improve acne pits and

scars. Kurtin’s description of dermabrasion actually

reintroduced Ernst Kronomayer’s dermabrasion

procedure, which Kronomayer had introduced in

Germany in 1905. Dermabrasion, chemical peeling

(trichloroacetic acid (TCA) and phenol) were consid-

ered standards for ASR until the 1990s.

The last decade has seen unprecedented technologi-

cal development of lasers, other light sources, and

radiofrequency (RF) approaches for ASR. They have

dominated the ASR arena, although a reverse trend

towards a return to chemical exfoliation exists in some

practices. Currently lasers, other light sources, and RF

devices are generally classified as ablative and nonabla-

tive. Goldberg6

has reviewed the four different tissue

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

biological effects of ASR devices on skin and adjacent

structures. The description traces the evolutionary

development of these devices:

1. The initial devices ablated the epidermis, caused

dermal injury, and provided a significant thermal

effect (carbon dioxide (CO2) lasers).

2. Subsequent devices caused highly selective

epidermal ablation, with minimal thermal effects

(erbium : yttrium aluminum garnet (Er:YAG)

short pulsed lasers).

3. Later devices ablated the epidermis, caused dermal

injury, and provided variable thermal effects (dual-

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

4. The more recent evolution of devices do not ablate

the epidermis, wound the dermis and provide

4. Erbium laser aesthetic skin rejuvenation

Richard Gentile


minimal thermal effects (nonablative lasers and

light sources).

The fifth generation of devices (not mentioned by

Goldberg) are nonablative or subablative devices that

produce a more substantial thermal effect for skin tight-

ening and rejuvenation, and include mono- and bipolar

RF devices, with or without optical energy, and infrared

and fractionated devices.Variable-pulsed Er:YAG lasers

are also included in this category, as these devices have

been developed to provide higher degrees of thermal

effects at the level of the dermis and perhaps below as

one function of their clinical application.

EVOLUTION OF USE OF ERBIUM

LASERS IN AESTHETIC AND MEDICAL

DERMATOLOGY

As reviewed by Ronel,7

laser technology applied to skin

resurfacing was discovered to yield more predictable

depths of injury when compared with chemical peels or

dermabrasion.The first laser used for laser-assisted skin

rejuvenation (LASR) was a pulsed CO2

laser that

Fitzpatrick and colleagues modified from a device that

had been developed for otolaryngological and gyneco-

logical use. It was initially utilized for periorbital and

perioral LASR, but initial appraisals of substantial aes-

thetic improvement led to its use for full facial rejuvena-

tion.The CO2

laser quickly became the workhorse for

LASR, and its advantages and limitations became well

recognized. Although the long-term skin rejuvenation

and tightening provided by this device are unparalleled,

marked erythema persisting for weeks or months and

permanent (sometimes delayed) hypopigmentation

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

In some patients, as with a deep phenol peel, the recov-

ery ‘downtime’ can approach 2 weeks, which may be

unacceptable for those with active lifestyles or work

obligations. Subsequent to the laser boom of the early to

mid 1990s, further research led to the development of

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

precise laser beam, resulting in less intense adverse side-

effects and a shorter recovery period. In 1990, Kaufman

and Hibst8

reported on the cutaneous laser ablative

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

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

experimental patients, treating superficial lesions such

as epidermal nevi. Precise control of epidermal ablation

was achieved, with small ablation depths and also ther-

mal necrosis rates that did not exceed 50 µm. Kaufman

and Hibst8

concluded that the laser should have poten-

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

dermal thermal depths of action, bleeding could be a

problem.

The Er:YAG laser was first introduced as a bone-

cutting tool in the USA in 1996, but commercial avail-

ability for LASR followed the completion of Food and

Drug Administration (FDA) studies of photodamage.

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

its ability to operate at a more superficial level and with

greater precision. Collagen contraction was noted to be

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

Concurrent with its introduction, some short

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

disadvantage of the superficial and fleeting energy

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

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

wound, so thermal necrosis does not significantly

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

wound bed does make controlling wound depth diffi-

cult.The blood spatter also creates more of a biological

hazard to the surgeon and assistants.The other limita-

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

contraction, although this may be due to the fact that

comparable depths of resurfacing are not being accom-

plished due to the lack of hemostasis.The shortcomings

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

logical modifications, which included a longer variable

pulse duration as well as the development of lasers with

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

allow the operator to dial in the depths of ablation as

well as the thermal effects (coagulation) desired.

ERBIUM LASER PHYSICAL

PROPERTIES AND LIGHT–TISSUE

INTERACTION

Erbium laser physical properties

Solid state lasers have lasing material distributed in a solid

matrix.Yttrium aluminum garnet (YAG,Y3Al

2(ALO

4)

3) is

a synthetic crystalline material of the garnet group



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

state lasers.YAG is commonly ‘doped’ with other ele-

ments to obtain a specific laser wavelength. In the

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

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

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

of 2940 nm. Its absorption bands suitable for pumping are

wide and are located between 600 and 800 nm, allowing

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

concentration used is high: about 50% of yttrium atoms

are replaced. The Er:YAG laser emission couples well

with water and bodily fluids, making these lasers espe-

cially useful in medicine and dentistry: Er:YAG lasers are

used for treatment of tooth enamel as well as aesthetic

dermatological applications. Er:YAG lasers are also used

for noninvasive monitoring of blood sugar.The mechani-

cal properties of Er:YAG are essentially the same as those

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

wavelengths (radiated incident through the lens is

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

work well at room temperature, and have high slope

efficiency. Er:YAG laser light is pale green.

Erbium laser light–tissue interaction

(biophotonics)

There are four primary interactions of laser light

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

reflection. There may also be scattering. This is then

followed by absorption by the target, and some of the

light may be transmitted through the tissues on the other

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

a remarkably strong function of wavelength.The result is

that lasers of different wavelengths have qualitatively and

quantitatively different interactions with tissue (Fig. 4.5).

The thermal relaxation time depends very strongly

on the absorption length.The absorption length is the

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

absorbed.Taken together, these two parameters deter-

mine a critical power density. This is the minimum

power density that must be used to limit thermal dam-

age to a depth equal to one absorption length (Table

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

0.001 mm, the thermal diffusion time is 4 µ, the criti-

cal power density is 600 W/mm2, and the critical

pulse energy is 0.0025 J/mm2.

In addition to the initial interactions of light with the

target, subsequent interactions can be summarized as

having photothermal, photochemical, or photoacoustic

effects on the target. As is widely recognized, the

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

more efficiently by superficial (water-containing) cuta-

neous tissue than is the CO2 laser emission at 10 600 nm.

Considering the typical short-pulse erbium pulse dura-

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

is accomplished at a fluence of 5. The vaporization

threshold of the Er:YAG laser is 0.5–1.7 J/cm2. The

fluence and depth of tissue ablation are directly related.

Erbium laser aesthetic skin rejuvenation 33

Fig.4.1 Yttrium aluminum garnet (YAG,Y3Al

2(AlO

4)3) is

used for synthetic gemstones.When doped with neodymium

(Nd3) or erbium (Er),YAGs are used as the lasing medium in

lasers.

Fig.4.2 Elemental erbium is a rare silvery rare earth

metal.Erbium is associated with several other rare

earth elements in the mineral gadolinite from Ytterby in

Sweden (from which both the names yttrium and erbium

are derived).


For every 1 J/cm2, 2–4 mm of tissue depth is ablated.

This allows for precise control of tissue ablation. It

occurs with minimal residual thermal damage and can be

compared with the 20–60 µm of tissue damage per stan-

dard pass of the CO2 laser with 150 µm of residual ther-

mal damage per standard pass.

Pulsed laser energy causes controlled vaporization

of the skin according to the principles of selective

photothermolysis. Target tissues contain chromo-

phores with absorption peaks that selectively absorb

the particular wavelength of the laser pulse. Tissue

adjacent to the chromophore absorbs the energy to a

much lesser degree. The interaction of target tissue

with the CO2

laser is predominantly a thermome-

chanical reaction that leads to target destruction of

dermal vessels and proteins. The Er:YAG laser inter-

acts with tissue via a photomechanical reaction.

Absorption of the optical laser energy causes imme-

diate ejection of the dessicated tissue from its loca-

tion at supersonic speeds.This popping sound (like a

cap gun) is audible and represents the microexplo-

sion taking place at the tissue level.The translation of

Er:YAG laser energy into mechanical work is an

important factor that protects the surrounding tis-

sue: minimal thermal energy remains to dissipate and

cause collateral damage.

COMMERCIALLY AVAILABLE

ERBIUM LASERS

While it is beyond the scope of this chapter to detail

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

some models that are or have been commercially


Optical resonator

(Laser medium)Er:YAG crystal

Flashlamp (pump source)

Highly reflectivemirror

Partially reflectivemirror

Laseroutput

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

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

lower-energy states.

Backward scattering Forward scattering

Transmission

Absorption

Laser beam

Directreflection

Fig.4.4 Biophotonics examines the interface of

laser and human tissue and is characterized by

reflection,absorption, scatter, and transmission.


available so that the laser’s unique specifications and

design can be understood.These will be listed as short-

pulsed systems, dual-mode systems, and variable-

pulsed systems.

Short-pulsed Er:YAG systems

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

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


Wavelength (µm)

Type of laser CO

2

KT

P

Pu

lse dye

Alexan

drite

Dio

de

Nd

:YA

G

Depth of Penetration

101−1

Er:Y

AG

Ab

sorp

tio

n c

oef

fici

ent

(cm

−1)

Melanin

Water

Hemoglobin

Scatter

Protein

105

104

103

102

101

100

10−1

10−2

10−3

10−4

0.1 1 10

Pigmentedtissue

Excimer

Ultraviolet Visible Infrared

0

1

2

Pen

etra

tio

n d

epth

(m

m)

3

40

KTPNd:YAG

Ho:YAG

Er:YAG CO2

Unpigmentedtissue

Wavelength (µm)

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

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

a

b


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

its release in 1996, the UltraFine Erbium was advo-

cated for incision, excision, ablation, vaporization, and

coagulation of soft tissue, including superficial skin

resurfacing, precision microplaning, etching, and tis-

sue sculpting. The laser vaporizes 20–50 µm of tissue

with very little thermal effect. It is equipped with a

computerized pattern generator as well as a variable-

width handpiece. The laser has a maximum output

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

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

very reliable. Others like it include the ConBio CB

Erbium/2.94 and the recently introduced Friendly-

light portable laser, which is highly transportable.

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

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

sparing intervening epidermis.The planned ablation is

20–50 µm per pass for epidermal ablation.

Dual-mode Er:YAG systems

Dual-mode, different laser type

Recent developments in Er:YAG lasers have led to the

combination of ablative and coagulative pulses (hence


Table 4.1 Critical power densities and minimum coagulation depthsa

Absorption length Thermal Critical power Critical pulse

(minimum damage zone) diffusion density energy

Laser (mm) time (s) (W/mm2) (J/mm

2)

Argon ion 0.1 pigmented 0.4 0.6 0.25

∞ unpigmented — — —

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

∞ unpigmented — — —

Nd:YAG 5 100 0.1 13

Hol:YAG 0.4 1 1 1.0

Er:YAG 0.001 4 × 10−6

600 0.0025

CO2

0.02 0.002 50 0.040

Electrocautery 2 16

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

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

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

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

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

Fig.4.6 The Coherent UltraFine Er:YAG laser

was one of the first to be available commercially,

in 1996.


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

ization with significant control of hemostasis. One of the

earliest dual-mode systems was the Sharplan DermaK.

(Both Coherent and Sharplan brands are now owned by

Lumenis.) Both the CO2

laser and Er:YAG laser are clin-

ically proven to be effective technologies for ablative skin

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

order to provide physicians access to the best character-

istics of each laser wavelength, Sharplan combined a

high-power Er:YAG laser and a subablative CO2

laser in

the blended DermaK system. DermaK has the unique

capability to deliver both Er:YAG and CO2

beams simul-

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

rejuvenation.

The Er:YAG laser carries out accurate ablation of

superficial layers, opening the way for the CO2

laser

to affect the deeper tissue layers. DermaK combines

the best of both the Er:YAG and CO2

lasers for

improved clinical efficacy. It replicates the precise tis-

sue ablation and minimal necrosis found in Er:YAG

systems and significantly controls the heating of

deeper tissue layers, typical of CO2

systems.The con-

current delivery of both wavelengths provides the

physician with enhanced control over hemostasis (dry

erbium technique), thereby increasing the range of

applications of the Er:YAG laser. The CO2

mode of

the DermaK delivers sufficient thermal energy to seal

small blood vessels throughout the surgical proce-

dure, creating the benefit of a clean, dry surgical field.

Simultaneous operation of both the Er:YAG and CO2

lasers minimizes the number of passes required for a

given procedure, thereby minimizing erythema and

decreasing the recovery time. At the same time, the

dual wavelengths allow more overall energy to be

transferred to the tissue, increasing the ablation depth

and controlling thermal impact. DermaK can also

perform many standard CO2

laser surgical and aes-

thetic incisional procedures, such as blepharoplasty.

There is generally no need for deep sedation when

treating most body areas in LASR.

Same laser type, variable pulse duration

Another dual-mode system is the Sciton Contour

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

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

neers use a technology called optical multiplexing to

generate multiple variable-length ‘macropulses’ to gen-

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

to 100 J/cm2

can be generated for aggressive vaporiza-

tion. Sufficient energy can be delivered to remove the

epidermis in one pass. The optical multiplexing also

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

bined ablative/coagulative dual mode, or a pure coagu-

lative mode. The ablative mode is characterized by a

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

ablation/coagulation is achieved by an ablative pulse

immediately followed by a relatively long subablative

pulse.The coagulative mode consists simply of a series

of subablative pulses.The Sciton Contour is the model

for many current lasers featured below.


Fig.4.7 The Sciton Profile is an example of a

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

as dual-mode devices.


Variable-pulse Er:YAG systems

Introduced in 2002, the Fontona laser systems feature a

proprietary VSP (Variable Square Pulse) technology.

This allows the practitioner to accommodate the laser

pulse duration and its fluence according to the needs of

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

online energy regulation, the energy of each pulse is

actively controlled to match the required value while

the laser is in operation.This enables the practitioner to

treat selected tissues without heating the surrounding

tissue unnecessarily.With a short pulse width, the VSP-

shaped Er:YAG laser induces minimal thermal effects to

underlying tissue while rejuvenating the superficial skin

layers through ablation of the epidermis.This allows the

practitioner to offer effective skin rejuvenation treat-

ments with higher comfort levels and shorter recovery.

By increasing the pulse duration, more heat is diffused

in the skin and a resulting collateral thermal effect is

achieved. Long-pulsed lasers characteristically have

pulse durations of the order of milliseconds, in contrast

to short-pulse durations of the order of microseconds.

These thermal effects produce pronounced collagen

contraction and new collagen stimulation in the dermis.

Clinical trials have proven a light ablative effect on the

epidermis, relatively noninvasive stimulation of new

collagen formation, and no post-treatment downtime.

Fotona’s stacked pulse technology provides a purely

nonablative Er:YAG laser SMOOTH mode for skin

rejuvenation treatments.The thermal SMOOTH mode

allows dermal remodeling and rejuvenation without

affecting the epidermis.

The Cynosure CO3 laser has a similar variable-pulse

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

10 ms.

The FDA has recently given approval for use in the

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

tures variable triple-pulse technology.The BURANE XL

features a specially designed and patented pulse sequence

for each application (coagulation, scars, and wrinkles)

that heats the deeper skin layers to a specific temperature

while protecting the epidermis by allowing it to cool

down during the pauses of the pulse sequences.All these

dosimetry models are based on longer pulse duration and

subablative laser energies for subablative dermal heating.

CLINICAL DERMATOLOGICAL

APPLICATIONS OF ERBIUM LASERS

Due to its superficial action and tendency to not pro-

mote dermal scarring, the Er:YAG laser is well adapted

to ablating and etching superficial cutaneous neoplasms

and cutaneous blemishes (Fig 4.9). The high ablative


Table 4.2 Dermatological conditions treatable with the Er:YAG laser

• Becker nevi • Trichoepitheliomas • Miliary osteomas

• Compound nevi • Sebaceous hyperplasia • Papillomas

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

• Verrucae • Xanthelasma • Syringomas

• Epidermal nevi • Adenoma sebaceum • Basal cell carcinoma

• Xanthelasma • Angiofibroma • Squamous cell carcinoma

• Syringomas • Hidradenoma • Telangiectasia

• Milia palpebrarum • Morbus Favre–Racouchot • Rhinophyma

• Seborrhoic keratoses • Lentigines • Hailey–Hailey disease

• Darier’s disease (familial benign pemphigus)

Long pulse

Low power

Ab

lati

on

sp

eed

Pulse duration (ms)

0 0.5 1.0 1.5

Th

erm

al e

ffec

t

High power

Short pulse

Fig.4.8 Biophotonics has also resulted in understanding

dosimetry of pulse duration and fluence in an attempt to

achieve more collateral thermal damage with the Er:YAG

laser in order to achieve better hemostasis as well as collagen

contraction.


potential results in microexplosive destruction of the

skin lesions without the associated scarring that would

result from epidermal or dermal excisions. Numerous

clinical applications are listed in Table 2.

CLINICAL AESTHETIC APPLICATIONS

OF ERBIUM LASERS

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

monly used for the improvement of fine rhytides. In

patients with moderate photodamage and rhytides,

modulated Er:YAG laser skin resurfacing results in

greater collagen contraction and improved clinical

results compared with short-pulsed Er:YAG systems.

The clinical improvement of severe rhytides treated

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

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

the endpoints of CO2

LASR can be reached even when

ablating to similar depths. Newman and colleagues

compared a variable-pulse Er:YAG laser with traditional

pulsed or scanned CO2

laser resurfacing for the treat-

ment of perioral rhytides.9Although a reduced duration

of re-epithelialization was noted with the modulated

Er:YAG laser (3.4 days vs 7.7 days with a CO2

laser),

the clinical results observed were less impressive than

those following CO2

laser resurfacing. Er:YAG laser sys-

tems may greatly improve atrophic scars caused by acne,


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

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

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

b

c d

a



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

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

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

a b

c

d


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

reported 70–90% improvement of acne scarring in the

majority of patients treated with a modulated Er:YAG

laser10

. Pitted acne scars may require ancillary proce-

dures, such as subcision or punch excision, for optimal

results.These procedures can be performed either prior

to or concomitant with Er:YAG laser resurfacing.

ERBIUM LASER TECHNIQUES

Cutaneous ablative surgery

In treating superficial epidermal lesions such as irri-

tated seborrheic keratoses, the primary lesion can be

ablated or an epidermal shaving of the lesion followed

by ablative pulses can be performed. On most treat-

ments with the short-pulsed laser system, the fluence

is set to 5, which corresponds to about 20 µm of abla-

tion. The lesion ablation is continued until the entire

lesion is vaporized.The adjacent dermis is ‘feathered’

to taper the cutaneous margins of the lesion.

‘Dry erbium’

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

resenting an epidermal ablation that does not extend

into the papillary dermis, where bleeding is encoun-

tered. Often, this treatment is done with subablative

levels of laser energy and is associated with rapid

recovery and a result that is intermediate to micro-

dermabrasion or photorejuvenation but not as signif-

icant as superficial laser resurfacing.

Superficial LASR

The technique used for superficial LASR is to set the

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

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

same settings are maintained until punctuate bleeding

is encountered.

Medium-depth LASR

The techniques utilized for medium-depth LASR will

be influenced by the Er:YAG laser technology available

and by other techniques that the laser surgeon can call

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

progression beyond 60–80 µm, there may be bleeding

from the dermal plexus, which will slow the proce-

dure down. It is our preference to change our tech-

nique if we wish to accomplish a deep LASR for

moderate to deep rhytides.When employing a combi-

nation technique for the full face, we generally

perform the CO2

laser resurfacing in the first pass,

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

using ablative bipolar RF (BPRF) (Visage, Arthrocare

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

dermis (Fig. 4.11) with several passes of ablative

BPRF.This technique serves to contract dermal colla-

gen without excessive thermal damage to the deeper

dermal layers.When treating acne scarring, we some-

times convert to dermal sanding in the deeper dermal

layers.

Deep LASR

Essentially the same techniques are utilized as in

medium-depth treatment, but the deeper dermal

treatment is performed with more passes.This is fre-

quently necessary for deeply creased upper lip rhytids.

It is important to always use a graduated approach

for deeper techniques and to treat the facial skin

with an appreciation of the skin thickness in each facial

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

occasionally utilize a fractionated CO2

laser pass after

completing the medium-depth LASR. This involves

spatially separated pulses of the CO2

laser over the

treatment area. The smallest possible spot size is

utilized, with no overlapping of pulses.

PATIENT SELECTION AND

PERIOPERATIVE MANAGEMENT

As with most aesthetic facial procedures, appropriate

patient selection and reasonable patient expectations

are the cornerstones of any successful intervention. A

complete medical and surgical history should be

obtained prior to any recommendations.

The contraindications to laser resurfacing are unre-

alistic patient expectations, a tendency toward keloid

or hypertrophic scar formation, isotretinoin use



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

compliance with postoperative instructions. Other

medical considerations include identifying patients

with reduced numbers of adnexal skin structures, such

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

prior ionizing radiation to the skin. These patients

should be approached with caution. Long-term use of

skin pharmaceuticals such as glycolic acid products or

retinoids may thin the dermis and alter the depth of

penetration of the LASR. A history of previous skin

rejuvenation procedures is noteworthy, because these

procedures could potentially slow the wound healing

process due to the presence of fibrosis. Patients who

have undergone prior transcutaneous lower lid ble-

pharoplasty or have limited infraorbital elasticity may

be at increased risk for postoperative ectropion.When

applicable, patients who smoke should be discouraged

from doing so before and after surgery to reduce the

risk of delayed or impaired wound healing.

Physical examination of the treatment area includes

careful attention to Fitzpatrick skin type and specific

areas of scarring, dyschromia, and rhytid formation.

For patients desiring periorbital laser treatment, the

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

ectropion. Other epidermal pathology should also be

noted, including seborrheic keratoses, solar lentig-

ines, actinic keratoses, and cutaneous carcinomas.The

author prefers to address this during the LASR, but

some lesions may need to be addressed prior to the

LASR.

LASR can lead to reactivation of latent herpes

simplex virus (HSV) infection or predispose the

patient to a primary infection during the re-epithe-

lialization phase of healing. Prophylactic antiviral

medication should be prescribed during the postop-

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

Currently used regimens include famciclovir 250 mg

twice daily, acyclovir 400 mg three times daily, or

valacyclovir 500 mg twice daily. The medication may

be administered the day before or on the morning of

laser resurfacing, and should be continued for 7–10

days or until re-epithelialization is complete.

Antibiotics for bacterial prophylaxis may be pre-

scribed; however, little data exist to support their

use, because of the relatively low incidence of post-

operative bacterial infections reported. The routine

use of antibiotic prophylaxis may increase the inci-

dence of antibiotic resistance and predispose patients

to organisms of increased pathogenicity. When used,

cephalosporin (cephalexin), semisynthetic penicillin

(dicloxacillin), macrolide (azithromycin), or

quinolone (ciprofloxacin) is administered 1 day

before or on the morning of surgery, and is continued

until re-epithelialization is complete.The use of topi-

cal antibiotics on the laser-induced wound may be

recommended, but neomycin-based products should

be avoided due to a 10% incidence of sensitivity to

this compound.

Postoperative wound care can follow an open or

closed method.With the closed method, a semiocclusive


Fig.4.11 Combination resurfacing techniques

utilize other modalities to achieve the same

endpoint that multiplexing pulse duration achieves.

Ablative bipolar radiofrequency or fractional CO2

laser treatment to the upper dermis enhances

hemostasis and collagen contraction.


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

wound dressings have been shown to accelerate the rate

of re-epithelialization by maintaining a moist environ-

ment. In addition, decreased postoperative pain has

been reported with their use.The closed method may

create a low-oxygen environment that may promote the

growth of anaerobic bacteria and subsequent infection.

As such, many proponents of the closed technique cur-

rently endorse removal of the dressing with wound

inspection 24–48 hours after the procedure, followed

by topical emollients.The open wound technique con-

sists of frequent soaks with cool saline or Domeboro

solution.These soaks are followed by the application of

ointment to promote re-epithelialization while allowing

adequate visualization of the resurfaced wound.

Er:YAG laser resurfacing ablates superficial cuta-

neous tissue and causes a thermal injury to denuded

skin.Therefore, some adverse effects are to be expected

and should be considered complications. These ‘side-

effects’ of cutaneous laser resurfacing include transient

erythema, edema, burning sensation, and pruritus.

Short-pulsed Er:YAG laser resurfacing procedures are

associated with a significantly shortened period of re-

epithelialization and erythema when compared with

the CO2

laser. However, when equivalent depths of

ablation and coagulation are achieved with the afore-

mentioned modulated systems, postoperative healing

times are comparable.

LASER RADIATION SAFETY AND

ERBIUM LASERS

All laser devices distributed for both human and ani-

mal treatment in the USA are subject to Mandatory

Performance Standards. They must meet the Federal

laser product performance standard, and an ‘initial

report’ must be submitted to the Center for Devices

and Radiological Health (CDRH) Office of

Compliance prior to the product being distributed.

This performance standard specifies the safety features

and labeling that all laser products must have in order

to provide adequate safety to users and patients. A

laser product manufacturer must certify that each

model complies with the standard before introducing

the laser into US commerce.This includes distribution

for use during clinical investigations prior to device

approval. Certification of a laser product means that

each unit has passed a quality assurance test and that it

complies with the performance standard.The firm that

certifies a laser product assumes responsibility for

product reporting, for record-keeping, and for notifi-

cation of defects, non-compliance, and accidental radi-

ation occurrences. A certifier of a laser product is

required to report the product via a Laser Product

Report submitted to the CDRH. Er:YAG lasers belong

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

lasers (500 mW for continuous-wave and 10 J/cm2

or

the diffuse reflection limit for pulsed), which are haz-

ardous to view under any condition (directly or dif-

fusely scattered), and are a potential fire hazard and a

skin hazard. Significant controls are required of class

IV laser facilities.

AVOIDANCE AND TREATMENT OF

COMPLICATIONS

Complications of Er:YAG laser resurfacing should be

differentiated from temporary ‘side-effects’ of the pro-

cedure.Temporary side-effects of Er:YAG laser resur-

facing include transient erythema, edema, burning

sensation, and pruritus. Healing times are short for the

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

models are designed to function more on a par with

CO2

laser systems and so the complication profile may

be similar, but appears to be intermediate in terms

of the most frequent complications of prolonged

erythema, hyper- or hypopigmentation, and dermal

fibrosis or scarring. In addition to the complications

mentioned above, mild complications of Er:YAG laser

resurfacing include milia, acne exacerbation, contact

dermatitis, and perioral dermatitis. Moderate compli-

cations include localized viral, bacterial, and candidal

infection.The most severe complications include dis-

seminated infection and the development of ectropion.

Diligent evaluation of the patient is necessary during

the re-epithelialization phase of healing.This is impor-

tant, because a delay in recognition and treatment of

complications can have severe deleterious conse-

quences, such as permanent dyspigmentation and scar-

ring.As always, patient selection and avoidance of these



procedures in any patient predisposed to delayed or

abnormal cutaneous wound healing will reduce the fre-

quency of severe postoperative sequellae.

Although short-pulsed Er:YAG laser resurfacing has

a significantly better adverse-effect profile and compli-

cation rate when compared with pulsed or scanned

CO2

laser resurfacing, long-term data for the modu-

lated Er:YAG laser systems are not yet available.

Because the modulated Er:YAG laser systems may be

used to create zones of collateral thermal damage

similar to those created by the CO2

laser, further studies

are necessary to determine the incidence of delayed

hypopigmentation.

REFERENCES

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

The Art and Science of Selective Photothermolysis, 2nd

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

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

MO: Mosby-Year Book, 1992:1–35.

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

Exanthemata. London: New Sydenham Society, 1874:

Vol 3:22–23.

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

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

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

Dermatol Syph 1953;68:389.

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

Dermatol 2003;4:225–34.

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

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

108.htm (accessed November 2006).

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

laser skin ablation – experimental results and first clinical

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

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

pulse erbium:YAG laser skin resurfacing of perioral

rhytides and side-by-side comparison with carbon dioxide

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

10. Weinstein C. Modulated dual mode erbium CO2

lasers

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

1:204–8.

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

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

554.htm (accessed November 2006).



INTRODUCTION

The name laser is an acronym for Light Amplification by

Stimulated Emission of Radiation. In 1917, Albert

Einstein was the first to theorize about the mechanism

that makes lasers possible, called ‘stimulated emission’.

In 1958, Charles Townes and Aurthur Schawlow theo-

rized about a visible laser system that would use infrared

or visible electromagnetic energy. Although some con-

troversy exists regarding the individual who invented

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

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

laser. In 1965, the carbon dioxide (CO2) laser was

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

a tremendous increase in theoretical and practical laser

knowledge, resulting in an explosion of laser technology

used in thousands of everyday applications.

One of the first individuals to report on the effects

of lasers on the skin was Leon Goldman, whom many

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

pioneering work using pulsed (ruby) and continuous-

wave argon lasers serves as the foundation for our

present understanding of laser medicine and surgery.

The first lasers used to treat skin conditions were

continuous-wave CO2

dioxide, argon, and argon-

pumped tunable dye lasers.The major disadvantage of

continuous-wave lasers is that the side-effects are

related to how long the beam is in contact with the

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

This resulted in high rates of complications, primarily

in the form of scarring.

In the late 1980s, the first pulsed lasers became avail-

able with the introduction of the flashlamp-pumped

pulse dye laser by the Candala Corporation. Pulsed

lasers were a major advance in laser medicine, since

energy delivery was now selectable and dwell time on

tissue became an independent factor in treatment.The

introduction of pulsed lasers greatly reduced the inci-

dence of scarring secondary to laser treatment.The sub-

sequent addition of cutaneous cooling during laser

delivery was another significant advance in cutaneous

laser surgery. Epidermal protection and increased

patient comfort secondary to cooling served to advance

the art and science of laser medicine.

In the early 1980s, there were few major companies

providing lasers for cutaneous application.Today, there

are dozens worldwide, and hundreds of laser devices are

available for use in the treatment of numerous congenital

and acquired skin conditions. Along with the explosion

of interest in cosmetic laser surgery came a tremendous

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

have seen a significant increase in side-effects and

complications associated with the use of lasers.

Since most laser and light sources ultimately are

designed to heat targets, complications secondary to

treatment using lasers and light sources is most often

related to excessive thermal energy delivered during

the procedure. It is this excess thermal energy that

most often contributes to unfavorable clinical results.

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

lasers that are common or anticipated and often

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

confine our discussion to complications that are events

not generally expected as a result of treatment.

Complications secondary to lasers and light sources

may be minor or serious, but all need prompt and

accurate diagnosis and treatment to prevent further

patient morbidity. As shown in Box 5.1, there are

numerous potential complications seen as a result of

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

5. Complications secondary to lasers

and light sources

Robert M Adrian


of most common causes of complications resulting

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

Box 5.1 Complications of lasers and light sources

• Ocular complications:

− Corneal

− Retinal

• Infection of personnel

• Hyperpigmentation

• Hypopigmentation

• Blistering

• Crusting

• Delayed wound healing

• Infection

• Cutaneous infarction

• Scarring

Box 5.2 Causes of complications from lasers and light sources

• Lack of basic knowledge and training on a specific

treatment modality

• Incorrect choice of laser or light source to treat a

clinical condition

• Failure to adequately recognize the clinical condition

confronting the operator

• Failure to anticipate, recognize, and treat common or

uncommon postoperative complications

• Failure to refer patients with evolving or non-

responding complications to more experienced

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

• Failure to adequately screen and counsel patients

prior to the procedure, thus avoiding postoperative

disappointment and frustration for both patient and

treating individual

LACK OF OPERATOR KNOWLEDGE

AND EXPERIENCE

The single most important cause of postoperative com-

plications is lack of proper training and experience of

the treating individual. The explosion of interest in

cosmetic laser treatments has served as a magnet for

those who wish to provide such services primarily for

the purpose of financial gain. Unfortunately, most of

these individuals are not willing to spend the time or

monetary investment learning the basic science of laser

surgery, treatment protocols, and techniques necessary

to provide safe and effective laser and light source-based

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

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

stantly unleashed on an unsuspecting public after a few

hours at an evening or weekend training session.

The use of a given laser or light source by any indi-

vidual should be complemented by a complete under-

standing of cutaneous structure and function, basic

dermatology, laser safety and physics, infectious diseases

of the skin, cutaneous wound care, and management of

common side-effects and complications. It is inconceiv-

able how any individual without prior knowledge or

training in dermatology could reasonably fulfill all of the


Fig. 5.1 Severe herpes simplex infection post carbon

dioxide laser resurfacing (by permission of Jean Rosenbloom)


above prerequisites during a single evening or weekend

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

only dermatologists or plastic surgeons are suitable to

perform laser- or light-based procedures, but rather

that non-dermatologist physician specialists or allied

health professionals should spend the necessary time

and effort to become properly trained prior to turning

themselves loose on their patients or clients.

INCORRECT CHOICE OF LASER OR

LIGHT SOURCE FOR A GIVEN

CONDITION

Despite the fact that there are hundreds of lasers and

light sources available to treat cutaneous conditions,

there are relatively few tissue targets or chromo-

phones available within the skin (Box 5.3). Although

it may seem intuitive, many individuals will often

use a given laser or light source to treat a condition

that is not within the technological scope of the

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

that this was related to lack of knowledge and experi-

ence, I have found that it is more often related to

monetary consideration on the part of the operator.

Common sense would suggest that one would choose

a laser or light source that would reasonably address

the target chromosphere – however, many examples

of laser clinical condition mismatches are seen in

clinical practice.

Box 5.3 Cutaneous chromophones

• Melanin

• Oxygenated hemoglobin

• Reduced hemoglobin

• Water

• Tattoo ink

• Iron

• Medication-induced pigment

• Foreign-body pigments

Complications secondary to lasers and light sources 47

Fig.5.2 Severe hypertrophic scarring secondary to CO2

laser burn

Fig.5.3 Hypertrophic scarring after long-pulse YAG laser

treatment of a tattoo.


FAILURE TO RECOGNIZE THE

PRESENTING CLINICAL CONDITION

Most physicians and allied health professionals with

training in cutaneous medicine can properly recognize

the clinical condition confronting them. Unfortunately,

inexperienced or untrained individuals often fail to rec-

ognize the presenting condition, resulting in worsening

of the condition or complications from treatment.

What excuse could one offer for treating a nodular

melanoma as a hemangioma or a linear verrucous

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

knowledge on the part of the physician? In addition,

many serious medical conditions, such as collagen

vascular disease, congenital neurocutaneous syn-

dromes, and vascular anomalies, present for cosmetic

treatment while actually needing proper diagnosis and

treatment rather than simply ‘cosmetic’ improvement.

FAILURE TO ANTICIPATE,

RECOGNIZE AND TREAT

COMMON POSTOPERATIVE

COMPLICATIONS

Most laser and light source treatments are accompanied

by various postoperative side-effects, which are defined

as conditions that are expected and directly related to


Fig.5.5 Perioral scarring secondary to CO2

laser

resurfacing.

Fig.5.4 Scarring and pigmentation from improper use of

an IPL DeviceFig.5.6 Scarring of the chest after CO

2laser resurfacing.

a

b


the procedure itself. Examples include purpura sec-

ondary to pulsed dye laser treatment, pinpoint bleeding

and crusting from Q-switch laser treatment, and

swelling and weeping of the skin after CO2

or Er:YAG

laser resurfacing. Complications, on the other hand, are

conditions that may or may not be expected, but are

caused by the procedure and are of significant nature to

require proper diagnosis and treatment. Such complica-

tions can be relatively minor, such as mild hypo- or

hyperpigmentation, edema, or minor crusting. Serious

complications include bacterial, fungal, or viral infec-

tions; severe pigment disturbances; and hypertropic and

keloidal scarring. Sepsis and systemic allergic reactions,

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

prompt proper diagnosis and treatment by skilled, well-

trained individuals. Failure to recognize and skillfully

address these complications is a major cause of post-

laser morbidity.

FAILURE TO TIMELY REFER PATIENTS

WITH EVOLVING OR

NONRESPONSIVE COMPLICATIONS

TO MORE EXPERIENCED

COLLEAGUES IN A TIMELY MANNER

All practitioners of laser- and light-based tech-

niques, regardless of experience, have encountered

postoperative complications. Morbidity secondary to

postoperative complications can often be greatly

reduced in most cases by arriving at the correct diag-

nosis and providing prompt treatment. Physicians who

fail to refer in a timely manner most often do so

because they actually fail to accurately diagnose the

presenting condition itself. Most often, I have encoun-

tered failure to recognize and treat postoperative viral

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

are treated for weeks with the wrong diagnosis, only

to rapidly heal when proper diagnosis and treatment is

intiated. Unfortunately, lack of training and lack of

experience lead to a failure of proper diagnosis and

treatment, causing significant morbidity for patients.

Again, proper training and experience are the primary

causes of late referral of complications.

FAILURE TO ADEQUATELY SCREEN

AND INFORM PATIENTS PRIOR TO

THE PROCEDURE

The cornerstone of a successful cosmetic and laser

practice is informed consent. Why? Because an ade-

quately informed patient will understand the risks,

benefits, and possible outcomes prior to the proce-

dure. Preoperative counseling with blunt and honest

answers prior to the procedure all but eliminate the

likelihood of postoperative patient dissatisfaction

and complaints. I have found that patients are much

more relaxed post-treatment when they had under-

gone a detailed discussion covering risks, benefits, and

realistic outcomes prior to the procedure. In my opin-

ion, informed consent is the single most important

factor leading to a smooth postoperative experience.

SUMMARY

There is no doubt that the use of lasers and light

sources has been one of the most significant advances

in cosmetic medicine and surgery in the last century.

Millions of people have benefited from new technolo-

gies to treat a wide variety of congenital and acquired

medical and cosmetic conditions. Unfortunately, many

Complications secondary to lasers and light sources 49

Fig.5.7 Scarring from smooth laser treatment of a tatoo


practitioners fail to undergo adequate training, resulting

in an unacceptable number of complications secondary

to the use of these new technologies.

Blame can be placed on all those involved: laser

companies who will sell or rent a laser or light source

to ‘any willing provider’ regardless of their level of

training or experience; practitioners who themselves

fail to undergo the necessary training in order to pro-

vide safe and effective laser procedures; and finally the

patients themselves, who fail to adequately evaluate

the training and experience of their provider prior to

the procedure and then complain that they had an

unfavorable result or complication. The internet age

has given patients powerful tools to ‘interview’ physi-

cians online, narrowing down the list of local experts

who will most likely provide more successful and safer

outcomes than their inadequately trained colleagues.

The explosion of laser day-spas, med-spas and non-

physician-supervised ‘laser centers’ presents a growing

challenge to patients to seek out experts in their com-

munity and avoid those who may ultimately do more

harm than good.



ABLATIVE VERSUS NONABLATIVE

To understand nonablative technology, it is important

to understand ablative technology, which came earlier.

Understanding the difference between the two

technologies puts their respective advantages and

weaknesses into perspective.

Ablative

In ablative skin resurfacing, the outer layers of skin are

vaporized and replaced by new collagen and epidermis

as wound healing occurs over days to weeks. Ablation

is possible because water has a high absorption coeffi-

cient in the infrared region. The most widely used

lasers for ablative resurfacing are the pulsed 10 600 nm

carbon dioxide (CO2) and 2940 nm erbium : yttrium

aluminum garnet (Er:YAG) lasers.The Er:YAG wave-

length is more efficiently absorbed by water, and thus

leaves little residual heat deposition to collateral tis-

sue, whereas the CO2

laser deposits more heat in the

surrounding area. This may be an important stimulus

to collagen renewal and hence skin tightening and

rhytid effacement,1

but leads to more complications.

In either case, the mechanism of renewal is epidermal

and dermal injury, which denatures collagen and acti-

vates fibroblasts, causing the synthesis of new collagen

and extracellular matrix material.2

Nonablative lasers were developed in response to

the two fundamental problems with ablative lasers:

long periods of downtime and the risk of long-term

hypopigmentation and scarring.

Nonablative

Nonablative lasers attempt to spare the epidermis and to

influence the dermis directly with light and/or radiofre-

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

no recovery period and thus no interruption of life’s

daily routines.Although efficacy is less than that of abla-

tive laser procedures, the dermal wound response from

nonablative laser treatments stimulates new collagen

production and repairs tissue defects.3

Energy is

deposited 100–500 µm below the skin surface, where

most histological changes (solar elastosis) associated with

photoaging occur. Nonablative laser procedures target

the dermis and avoid epidermal damage by cooling dur-

ing treatment,4–10

as well as targeting chromophores

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

addition, the wavelengths utilized for nonablative lasers

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

magnetic spectrum and penetrate to the upper and

mid-dermis – the target zone.

A variety of studies5,7,11–19

indicate that skin tighten-

ing and wrinkle reduction months after nonablative

laser or light therapy are associated with collagen

remodeling.This relationship was established by com-

paring clinical improvement with changes in histologi-

cal characteristics, ultrastructure, and biochemical

constituents known to play a role in wound healing

and the production of dermal collagen.

Microablative

Fractional photothermolysis (FP) has recently

been introduced for ‘microablative’ resurfacing.20,21

6. Nonablative technology for

treatment of aging skin

Amy Forman Taub


Although FP is associated with limited downtime and

usually requires multiple sessions, its main mechanism

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

ablative and nonablative techniques.

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

pattern of microscopic thermal wounds rather than

uniform thermal damage in the skin.These microther-

mal zones (MTZs) are typically 100 µm wide and

300 µm deep and are surrounded by undamaged

tissue, thus promoting a rapid healing response. The

density and space between MTZs can be adjusted for

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

discomfort are manageable.20,22

This results in more rapid epithelialization than with

ablative therapy, as well as deeper penetration into the

dermis, with the possibility of eliminating abnormal

dermal deposits and/or breaking up scars mechani-

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

6.2 and 6.3.

NONABLATIVE TECHNOLOGIES FOR

PHOTOREJUVENATION

Many nonablative devices have been developed over the

past 10 years.There are infrared devices targeting super-

ficial collagen with nonspecific heating, pulsed dye lasers

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

other parts of the dermis, long-pulsed neodymium

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

emitting diode (LED) devices, photodynamic therapy

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

cause three-dimensional changes in the skin through

nonablative methods. Each of these modalities will be

discussed in the following sections.

Laser or visible light technology

In photorejuvenation, technologies with wavelengths

in the visible spectrum target the upper dermis. Many


100 µm

0 days

100 µm

1 days

100 µm

3 days

100 µm

7 days

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

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

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

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

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

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

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

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

Technologies, Inc.)

a b c d


lasers and light sources have been developed with the

principal use in mind of removing excessive epidermal

pigmentation, reducing upper dermal telengiectasia,

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

been noted by a number of investigators that these

modalities also seem to improve superficial wrinkles

and cause some skin smoothing and tightening.

Pulsed dye laser

As the first laser developed to apply the principle of

selective photothermolysis, the 585 nm PDL remains the

gold standard for the treatment of vascular lesions.23

Zelickson et al13

reported the first investigation of

the PDL for the treatment of sun-induced facial

rhytids. Histological examination revealed dermal

changes consistent with collagen remodeling. These

results were confirmed in 2000 by Bjerring et al24

who, by altering the pulse duration, obtained cosmetic

improvement without purpura. Tanghetti et al25

reported similar clinical improvements in facial dys-

pigmentation and wrinkling after single-pass and dou-

ble-pass treatment with either 585 nm or 595 nm PDL

devices. In a controlled, split-face study, Hsu et al26

reported improvements in surface topography of 9.8%

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

by histological evidence of collagen remodeling.

Key studies are summarized in Table 6.1.

Intense pulsed light

Generally considered the gold standard for the nonabla-

tive treatment of superficial photodamage, IPL therapy

achieves selective photothermolysis with noncoherent

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

broad spectrum of visible light, the two main chro-

mophores, hemoglobin and melanin, can be effectively

targeted with only one piece of technology.The minimal

risk and downtime associated with this procedure have

contributed to its success.8

Two key studies were reported in 2000. Bitter11

showed that serial full-face treatments with IPL visibly

improved wrinkling, irregular pigmentation, skin

coarseness, pore size, and telangiectasias in more than

90% of patients with little downtime.The patient sat-

isfaction rate exceeded 88%. A clinical example and

photomicrographs of biopsy specimens are shown in

Figs 6.4 and 6.5, respectively. Goldberg and Cutler27

showed that IPL therapy nonablatively improved facial

rhytids and skin quality with minimal adverse effects.

Other studies are summarized in Table 6.2. Using

treatment parameters similar to those used by Bitter,

Negishi and colleagues28,29

showed that IPL improved

pigmentation, telangiectasias, and skin texture of

Asian skin. Goldberg and Samady30

revisited perioral

rhytids, using different IPL parameters and comparing

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

Nonablative technology for treatment of aging skin 53

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

three treatments of a woman with

melasma and textural irregularities

treated with a fractional device,

6–8 mJ,density level 6,with eight

passes. (Photographs courtesy of Amy

Forman Taub MD.)

a b


satisfaction rates were similar, although blistering and

erythema were more common with IPL. In a

93-patient study, Sadick et al31

showed that up to

five full-face IPL treatments resulted in significant

improvement in a variety of clinical indications of

photoaging. A newer technology combining IPL with

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

by Sadick et al31

and found to be at least as efficacious


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

old man whose acne scars had

been treated three times

unsuccessfully with

trichloroacetic acid (15%)

peels. (c,d).After a single

fractional photothermolysis

session, the acne scars are

markedly improved 4 weeks

later.Skin texture was also

improved. (Reproduced with

permission from Hasegawa T,

Matsukura T,Mizuno Y,Suga

Y,Ogawa H, Ikeda S.Clinical

trial of a laser device called

fractional photothermolysis

system for acne scars. J

Dermatol 2006;33:623–7.)

a b

c d


for pigmentation and vascularity but potentially more

advantageous for pore size, superficial rhytides, laxity

and texture due to the addition of the RF modality

which can penetrate more deeply into the dermis to

stimulate collagen remodeling.

Potassium titanyl phosphate

The 532 nm wavelength of the potassium titanyl

phosphate (KTP) laser device is readily absorbed by

oxyhemoglobin and melanin,34

making it especially


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

Areas/ Wavelength

conditions (nm)/Fluence

No. of treated (No. (J/cm2

)/Pulse Adverse Follow-up

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

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

perioral and 0.45 wrinkling showed 50% or purpura,

periorbital greater improvement at swelling

wrinkles (1) 6 months, 3/10 with

moderate to severe

wrinkling showed clinical

improvement at 3 months

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

wrinkles (1) 0.350 decreases in Fitzpatrick

class I, II, III wrinkles

25 17 Facial 585 or 595/ Clinically observable None 6

dyspigmentation 3–4/0.5 improvement in

and wrinkling (4) dyspigmentation

and wrinkling for

all subjects

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

wrinkling 0.35 topography of 9.8% during initial

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

15% (two treatments) temporary reddening

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

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

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

a b


effective for treating red and brown discolorations due

to photodamage35

and inducing growth of collagen and

elastin fibers when endothelial damage causes the

release of cytokines.34

Combining the KTP laser with

the 1064 nm Nd:YAG laser device15,35

makes use of the

greater penetration depth of the longer wavelength to

create a synergistic effect that further improves skin

quality and wrinkle reduction beyond what is achiev-

able by KTP alone (Figure 6.6).15

The efficacy of the KTP laser is comparable to that of

IPL.36

The smaller spot size and ergonomic flexibility of

the KTP handpiece, however, promote ease of use and

allow practitioners to focus on resistant lesions.34

Although fewer treatments are required, the risk of

erythema and edema is higher with the KTP laser21

and the treatment is less tolerable.36

The results of key studies are presented in Table 6.3.

Photomodulation

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

used to manipulate cellular activities without thermal

effect.37

McDaniel and colleagues showed37,38

that they

could upregulate procollagen synthesis and downregu-

late matrix metalloproteinase (collagenase) in fibro-

blast culture with specific pulse sequences and

durations of low-energy, narrowband, or coherent

light. The effects were strongest when 590 nm LED

devices were used.

These findings led to a multicenter trial in which 90

patients with photodamaged skin received eight LED

photomodulation treatments using a full-panel 590 nm

nonthermal full face LED array delivering 0.1 J/cm2

with a specific sequence of pulsing treatments over 4

weeks.12

More than 90% showed improvement in at

least one Fitzpatrick photoaging category and 65%

showed improvement in facial texture, background

erythema, fine lines, and pigmentation, all without

pain or adverse effects. Improvements peaked in 4–6

months after the final treatment. The clinical results

were supported by post-treatment histological studies

that showed increased collagen in the papillary dermis.

The use of combination 633 nm and 830 nm LED

light therapy for the treatment of photodamaged skin

has been reported by two groups.19,39

In a 31-patient

study, Russell et al39

treated facial rhytids nine times

and noted (1) 25% to 50% improvement in photo-

aging scores of 52% of patients and (2) significant

patient-reported improvement in periorbital wrinkles

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

In a similar 36-patient study, Goldberg et al19

reported

very similar results. Electron microscopic data of post-

treatment tissue showed collagen fibers of increased

thickness. Adverse effects were limited to mild

erythema in one patient.


Fig.6.5 Photomicrographs of biopsies of forehead skin

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

4 weeks after the fifth IPL treatment. (Reproduced with

permission from Bitter PH Jr.Noninvasive rejuvenation of

photodamaged skin using serial, full-face intense pulsed light

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

a

b



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

Areas/ Cut-off filter

conditions (nm)/Fluence

No. of treated (No. (J/cm2)/Pulse Adverse Follow-up


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

rhytids improvement, 9/30 erythema,

(1–4) substantial improvement blistering

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

photorejuvenation 30–50/ reported erythema, blisters,

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

improvement lentigines and

freckles

28 97 Facial 550 or 570/ 88.4% of patients reported 0a

(Asian photorejuvenation 28–32/2.5–5 ≥ 51% improvement

skin) (3–6) in pigmented lesions,

77.7% reported ≥ 51%

improvement in

telangiectasias, 77.3%

reported ≥ 51%

improvement in

skin texture

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

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

6.4 (at 590 nm), 6.2 with IPL

(at 755 nm) at 6 months

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

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

skin) (1–3) hyperpigmentation,

crusting

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

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

dyschromia, dyschromia, pore size purpura

pore size

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

photoaging 890–1200/ texture, mottled treatment, transient

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

duration not solar lentigines, erythema/ crusting, erythema

reported telangiectasias

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

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

pigmented lesions and pigmented lesions; hyperpigmentation

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

patients at 6 months;

patient satisfaction high

aResults were evaluated at the end of the third treatment.


LEDs are promising, as they are less expensive to

manufacture, they take only seconds of irradiation, and

they are painless. They have also been used to reduce

inflammation in sunburn and provide palliation for breast

cancer metastatic to the chest wall, and more novel indi-

cations for this modality may be discovered in the future.


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

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

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

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

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

Areas/ Fluence

conditions (J/cm2)/

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


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

mild to moderate erythema, edema;

improvement in sensitivity to heat

appearance of rhytids, and recurrence of

moderate improvement flushing and

in skin toning and texture, telangiectasias in

great improvement in patients with

reduction of pigmentation rosacea; mild to

and redness; KTP results moderate pain

superior to 1064 nm laser during and

results after treatment

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

and midfacial 13–17 improvement in all erythema

(4) patients, all patients

pleased with results

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

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

telangiectasias pigmented lesions erythema, crusting of

(1) dyschromias

a b


Photodynamic therapy

PDT uses a light-activated photosensitizing agent

to create cytotoxic singlet oxygen within abnormal

tissue. Because the photosensitizer accumulates pref-

erentially in abnormal cells, PDT selectively destroys

these target cells without damaging surrounding

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

is approved by the US Food and Drug Administration

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

in the face and scalp, the technique is being used

to treat a wide variety of skin conditions (including

photorejuvenation) because of its efficacy, safety

profile, and minimal downtime.40

Photodynamic rejuvenation denotes the use of PDT

to improve the clinical manifestations of photodam-

age.41

Touma et al42

showed that 1-hour ALA incuba-

tion provided approximately the same improvement in

photodamage as 14- to 18-hour ALA incubation and

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

photodamage. A variety of studies have led to the rec-

ommendation40

that either IPL (preferred), blue light

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

photosensitizer when ALA–PDT is used for photo-

rejuvenation.

One of the advantages of PDT is its ability to

be performed with many different technologies.

Protoporphyrin IX is the photoabsorbing molecule, and

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

there are multiple Q-bands of absorption up to about

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

light, and LED diodes all will activate the photosensitizer

and be able to produce a photodynamic treatment.

Another huge advantage of PDT is that it can eradicate

precancerous cells while improving photodamage

(Fig. 6.7).

Blue light, red light, LEDs,43

ELOS,44

PDLs, and

IPL have been used in PDT for photorejuvenation.Two

topical photosensitizers are currently in use: ALA and

methyl aminolevulinate.

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

Table 6.4. Split-face studies45–47

have shown the superi-

ority of PDT with IPL versus IPL alone.

Long-wavelength lasers and light

sources for collagen stimulation

Collagen remodeling with the use of infrared lasers has

been extensively studied. Early studies7,16,17

using the

1320 nm Nd:YAG laser showed minimal to visible clin-

ical improvement in facial rhytids, with histological evi-

dence of dermal collagen 1–6 months after the final of

a series of treatments. Results with the 1540 nm

Er:glass laser were less encouraging, possibly because

collagen denaturation and dermal fibroplasia had

occurred too deeply in the dermis to improve wrin-

kles.5

A 24-patient study52

showed gradual clinical

improvement in mild to moderate facial rhytids during

and 6 months after a series of three once-monthly

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


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

(Photographs courtesy of Michael Gold MD.)

a b



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

light, for photorejuvenation.

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

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

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

(tactile skin roughness);

90 (mottled

hyperpigmentation);

70 (facial erythema);

83 (actinic keratosis)

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

contact 72 (skin texture);

59 (skin pigmentation)

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

(telangiectasias); 48 transient

(pigment irregularities); erythema,

25 (skin texture) edema

45 Not — IPL 3a, 2

b80 (ALA–PDT–IPL) — 1

available vs 50 (IPL) photoaging;

95 vs 65 (mottled

hyperpigmentation);

55 vs 20 (fine lines)

46 13 — IPL 3a

55 (ALA–PDT-IPL) vs Erythema, 3

29.5 (IPL) crow’s feet; edema

55 vs 29.5 (tactile skin

roughness); 60.3 vs

37.2 (mottled

hyperpigmentation);

84.6 vs 53.8 (facial

erythema); 78 vs 53.6

(actinic keratosis)

51 10 1 IPL 2a

1.65a(ALA–PDT–IPL) Temporary 6

vs 1.28c

(IPL) erythema, mild

edema,

desquamation

47 20 0.5–1 IPL 3a, 2

b80 (ALA–PDT–IPL) vs Mild stinging 1

45 (IPL) global score; during treatment;

95 vs 60 (mottled temporary

hyperpigmentation); 80 vs erythema, scaling,

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

90 (tactile roughness); crusting,

75 vs 75 (sallowness) vesiculation

aSplit face,ALA–PDT–IPL vs. IPL.

bFull face, IPL alone.

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

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

J Drugs Dermatol 2006; 5:140–54.


increase in dermal collagen was not observed until sev-

eral months after the final treatment. A recent review

of clinical trials with the 1540 nm Er:glass laser53

con-

firmed that collagen remodeling and improvement

were gradual, and emphasized the importance of

explaining this to patients.

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

studies of Lee15,54

revealed subtle and gradual

improvements in wrinkles, skin laxity, and overall

appearance, supported by histological evidence of

collagen remodeling. In another study,55

a series of

four treatments with a 1450 nm diode laser

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

in mild to moderate improvement in facial rhytids in

all 25 patients treated and increases in dermal colla-

gen 6 months after the final treatment.The treatment

was well tolerated, and adverse effects were transient

and limited to erythema, edema, and postinflammatory

hyperpigmentation.

Two other groups56,57

have reported clinical evalua-

tions of the 1064 nm Nd:YAG laser. Dayan et al56

found an approximately 12% reduction in Fitzpatrick

scale scores for coarse wrinkles, a 17% reduction for

skin laxity, and a 20% overall improvement. Taylor

and Prokopenko57

reported a 30% improvement in

wrinkles and skin laxity and an approximately 16%

improvement in texture, pores, and pigmentation.

Dang et al58,59

focused on head-to-head comparisons

on mouse skin. In one study,58

they compared the

histological, biochemical, and mechanical responses

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

and the 1320 nm Nd:YAG laser.The 1064 nm laser pro-

duced a 25% greater improvement in skin elasticity, a

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

greater hydroxyproline synthesis (a measure of colla-

gen content59

) by the second month after treatment.

Type III collagen increased markedly after 1064 nm

laser treatment, while type I collagen increases were

greater after treatment with the 1320 nm laser.

In another study59

comparing a 595 nm PDL (Vbeam,

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

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

CA), PDL treatment produced a greater increase in der-

mal thickness, hydroxyproline levels, and type I and type

III collagen, while improvement in skin hydration was

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

differences was statistically significant.

Orringer et al60

assessed collagen remodeling after a

single treatment of photodamaged skin with either

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

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

Pharmaceuticals Inc.).At 1 week post treatment, histo-

logical examination revealed statistically significant

increases in type I procollagen messenger RNA expres-

sion (47% and 84% above pretreatment levels for the

585 and 1320 nm lasers, respectively), as well as induc-

tion of primary cytokines, matrix metalloproteinases,

and type III procollagen.

Doshi and Alster61

evaluated the combination RF and

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

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

This device delivers RF and 910 nm diode laser energy


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

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

a b


sequentially through a bipolar electrode tip with

epidermal cooling. Three treatments were given at

3-week intervals to 20 patients with mild to moderate

rhytids and skin laxity. Optical and RF fluences ranged

from 30 to 40 J/cm2

and from 50 to 85 J/cm3, respec-

tively. The prospective study showed a mean clinical

improvement of superficial rhytids at 6 months of

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

ment scores reached 2.00/4 at 6 months. Patient

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

combined study62

of ELOS with both IPL and a diode

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

measures of photodamage was approximately 26%.

NONABLATIVE TECHNOLOGIES FOR

SKIN TIGHTENING

From the evidence that collateral heating of the dermis

while targeting vascular and pigmented lesions created

new collagen and decreased wrinkles sprang the idea of

bulk dermal heating. Bulk dermal heating requires rela-

tively deep energy deposition over a period of seconds

as opposed to microseconds, with cooling to protect

the epidermis.The intent of tissue tightening is to actu-

ally lift or firm tissue in a three-dimensional manner.

This is not the same as stimulating collagen to fill in

superficial scars or wrinkles, but a deeper shift in tissue

volumes, leading to a remodeling of the entire soft

tissue envelope, a completely new aesthetic capability.

Collagen fibers consist of protein chains held in a

triple helix. When collagen is heated, non-colavent

bonds linking the protein strands together are rup-

tured, producing an amorphous arrangement of ran-

domly coiled chains.63

As the chains rearrange, fibers

of the denatured collagen become shorter and thicker.

Heat-induced contraction of collagen and long-term

fibroblastic stimulation are is the basis for the treat-

ment of skin laxity.64

For exposures lasting several seconds, the denaturation

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

In practice, however, collagen denaturation has a complex

dependence on temperature described by the Arrhenius

reaction-rate equation.This relationship may not hold for

very short time exposures to heat, because the kinetics of

collagen denaturation are not known.66

There are two technologies supported by peer-

reviewed literature at present for evaluation: RF and

broadband infrared (IR) light.

Radiofrequency-based tissue

tightening

RF energy interacts with tissue to generate a current

of ions that, when passed through tissues, encounters

resistance. This resistance, or impedance, generates


Fig.6.9 Partially denatured collagen

after Thermage treatment as 160

microns by electron microscopy.

(Reproduced courtesy of Dr.Brian

Zelickson and Thermage Corp.)



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

Ref No. of Fluence Areas Adverse Follow-up

patients (J/cm2) treated Efficacy effects (months)

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

anterior noticed significant during treatment;

neck improvement in 3/40 patients

skin laxity and experienced

texture at 3 months superficial blistering

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

for 2 nasolabial folds: 50% of discomfort

patients patients had at least 50% during treatment

treated with improvement; cheek contour: in all patients;

1 cm2

tip) 60% had 50% improvement; superficial

mandibular line: 27% had at burn (1 patient)

least 50% improvement;

marionette lines: 65% had

at least 50% improvement.

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

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

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

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

to very satisfied; 61.5% of 3 patients

eyebrows lifted by 0.5 mm

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

line, upper neck were satisfied with results erythema and edema

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

nasolabial folds, erythema

puppet lines

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

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

74–110 skin laxity satisfaction was similar rare dysesthesia

(neck) in neck to observed clinical

and cheek improvement

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

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

elevation; improvement; patient redness

forehead, satisfaction low; 72.7%

temporal said they would not have

regions the procedure again;

results not predictable

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

wrinkles, pores, improvement in wrinkles

pigmentation, and skin laxity; about 16%

texture improvement in texture,

pores, and pigmentation;

patients satisfied; improvement

maintained 2–6 months


heat in proportion to the amount of impedance.

Tissues with high impedance will be heated more than

tissues of low impedance.67

Traditional RF devices used in skin surgery deliver

therapeutic energy through the tip of an electrode

in contact with skin. The concentrated thermal

energy produces heat at the surface of the skin, which

injures both the dermis and epidermis.68

To reduce

heat-induced epidermal injury while heating the der-

mis, developed the ThermaCool, a device that delivers

RF energy to the skin via a thin capacitive coupling

membrane that distributes RF energy over the tissue

volume beneath the membrane’s surface (rather than

concentrating the RF energy at the skin surface) while

cooling the epidermis by cryogen spray.69,70

Although

the deep dermal layer can theoretically reach tempera-

tures exceeding 65°C, permitting the heat-sensitive

collagen bonds to go beyond their 60° denaturation

threshold, the temperature of the epidermis is main-

tained between 35°C and 45°C.68

A study of the histo-

logical and ultrastructural effects of RF energy

suggested that collagen fibrils contract immediately

after treatment and that production of new collagen is

induced by tissue contraction and heat-mediated

wounding (Fig. 6.9).71

The first clinical study of the ThermaCool assessed

skin contraction, gross pathology, and histological

changes for a range of RF doses.70,72

Iyer et al73

reported that 70% of patients noticed skin laxity

improvement 3 months after a single RF treatment and

that improvement increased with additional treat-

ments. A subsequent report described a prototype

device designed to produce heat in the dermal layer of

tissue while protecting the epidermis by cryogen spray


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

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

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

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

a b


cooling.74

Of the 15 patients,14 responded to a single

treatment without wounding or scarring. Pain was

used to indicate the tolerability of treatment. Patients

resumed normal activities immediately after treat-

ment.

Other RF studies that followed are summarized in

Table 6.5. In each study, patients had a single treat-

ment, local anesthesia was used during treatment, and

results were evaluated by comparing pre- and post-

treatment photographs. Improvements with a single

treatment were gradual and subtle and lasted for sev-

eral months. Higher fluences were required with thick

skin.69

When low fluences were used, improvements

were less pronounced.70,75

Initially, it was believed that the highest fluences

would yield the best results. However, this was accom-

panied by significant patient discomfort and a rela-

tively high rate of significant side-effects,76

such as

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

tation or waffling). A different model based on a

lower-fluence, multiple-pass protocol was shown via

ultrastructural analysis of collagen fibril architecture

to provide much more collagen deposition deeper in

the dermis than the high-fluence protocol.77

This is

believed to yield more consistent results, higher

patient tolerability, and fewer complications. Recent

advances include specialized tips for more superficial

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

Infrared light-based tissue tightening

A broadband infrared light tightening device has

recently been developed as an alternative technology

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

This generates energy of up to 50 J/cm2

energy at

1100–1800 nm wavelengths, with pre- and postcool-

ing being built into the multisecond pulse. The long

wavelengths of near- and mid-IR radiation offer three

major advantages over shorter wavelengths: (1) deeper

penetration into the dermal layer (2) less absorption

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

patients.56

This device targets the dermis at a depth of

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

The author has found this to be an advantage for thin-

ner skin, whereas the RF technology may be better for

thicker skin with more subcutaneous tissue attached –

but these observations are anecdotal. However, in

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

Studies of the use of infrared light in tissue tightening

are summarized in Table 6.6.

THE FUTURE AND CONCLUSIONS

A major advantage of nonablative techniques is that

treatment requires little or no downtime for patients.

The importance of this feature is evident from the


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

Device

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

Ref patients treatments) (J/cm2) anesthesia target Efficacy effects (months)

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

1800 nm patients lower improvement in 22 burns

(1–3) face and patients, persisted

neck for follow-up period;

all patients satisfied

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

1800 nm neck, moderate or minor

(2) abdomen higher in 52.4% swelling

of patients and

erythema,

rare blister


growth and proliferation of nonablative devices since

they were introduced in the late 1990s. Disadvantages

are that efficacy is modest and multiple treatments are

required to achieve results. Future efforts will be

focused on increasing efficacy and reducing the num-

ber of treatments, making treatment more affordable

for more patients.

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INTRODUCTION

Acne vulgaris is an exceedingly common multifactorial

disease of the pilosebaceous unit, believed to affect

approximately 40 million adolescents and 25 million

adults in the USA alone.1

It is thought to be physiologic

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

people between the ages of 12 and 24 years.2

However,

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

clinical acne until the age of 44.3

Many authors have

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

can be disfiguring, patients with acne often carry signif-

icant psychosocial morbidity, including anxiety, sleep

disturbances, clinical depression, and suicide.4–8

In many cases, acne can be successfully treated using

conventional topical or oral medications such as

antibacterials, antimicrobials, and retinoids. However,

this approach often has drawbacks involving side-effect

profiles, length of treatment, and patient compli-

ance.9–13

With oral retinoids, practitioners are faced

with federally mandated paperwork that takes not only

time, but also several patient visits in order to deliver

treatment.14,15

For the subset of patients who have failed these

treatment modalities, laser and light-based systems

have emerged as standalone and adjunct therapies.

These devices work by targeting the components of the

pilosebaceous unit that lead to acne lesions, namely

either the resident bacterium Propionibacterium acnes,

inflammation, or the pilosebaceous unit itself.

THE BUILDING BLOCKS OF ACNE

VULGARIS

In order to select the appropriate device for treating

acne, it is essential to understand the pathogenesis of

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

broken down into lesion types based on pathogenesis

and severity: comedones, inflamed papules, nodules,

and cysts. The majority of data involving laser and

light-based therapies are based on the treatment of the

non-cystic form of acne vulgaris.

Simply put, acne has four main pathophysiological

features: hyperkeratinization, sebum production,

bacterial proliferation, and inflammation. The early

comedone is produced when there is abnormal pro-

liferation and differentiation of keratinocytes in the

infundibulum, forming a keratinous plug. This leads

to impaction and distention of the lower infundibu-

lum, creating a bottleneck affect.As the shed keratino-

cytes form concretions, the sebum in the follicle thus

becomes entrapped. This stage represents the nonin-

flammatory closed comedone. As accumulation

increases, so too does the force inside the follicle

itself, eventually leading to rupture of the comedo

wall, with extrusion of the immunogenic contents

and subsequent inflammation. Depending on the

nature of the inflammatory response, pustules, nod-

ules, and cysts can form.

One factor in the pathogenesis of acne vulgaris is the

role of the resident P. acnes found deep within the seba-

ceous follicle.16–18

P.acnes is a slow-growing, gram-posi-

tive anaerobic bacillus. It contributes to the milieu of

acne production in the lipid-rich hair follicle by pro-

ducing proinflammatory cytokines (e.g., interleukin-1

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

as many lipases, neuraminidases, phosphatases, and

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

years prior to sexual maturity, when numbers can

reach approximately 106/cm

2, predominantly on the

face and upper thorax.19

Although some suggest that

the absolute number of P. acnes does not correlate

with clinical severity,16

it is common belief that the

7. Lasers, light, and acne

Kavita Mariwalla and Thomas E Rohrer



Sebum

Resident P. acnes

Hair shaft

Pore

Sebaceouslobule

The pilosebaceous unit

Hair shaft

Pore

Retained keratinand lamellarconcretions

Inflammation

Sebaceouslobule

regression

P. acnesproliferation

Inflammatory papule/pustule

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

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

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

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


proinflammatory mediators released by these bacteria

are at least partially responsible for the clinical acne

lesion.

In practice, acne is predominantly found on the face

and to a lesser degree on the back, chest, and shoul-

ders.The majority of studies using laser and light-based

systems target acne on the face, although we present

data from a limited number of studies performed else-

where on the body.

CLINICAL EXPERIENCE AND

CONSIDERATIONS

Patient screening

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

treatment of acne vulgaris, the selection of patients

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

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

simple guidelines before initiating laser or light-based

therapies.

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

2. Has the patient tried isotretinoin or are there

circumstances that make isotretinoin a less-than-

ideal medication for the patient?

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

inflammatory acne papules as well? To what extent

is the patient’s acne nodulocystic?

4. Does the patient have acne and acne scarring?

It is important to keep in mind that most laser

systems will work to some extent. Topical and oral

medications should be optimized and are generally

continued during the initial phase of treatment with

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

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

without topical and oral medications, in patients

presenting with both active acne and acne scars who

also want treatment of their scars.

The patient encounter

In the initial evaluation of the patient, it is important

to set realistic expectations. Although many patients

see dramatic improvement with laser and light-based

therapy, some see little to no improvement. Compared

with conventional therapy, laser and light devices

require no daily routine, are not altered by antibiotic

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

to administer, and some (infrared and radiofrequency

devices) offer significant textural improvement of acne

scars. On the other hand, these modalities are much

more expensive, involve some degree of patient dis-

comfort during treatment, have post-treatment recov-

ery/downtime due to erythema, and require multiple

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

procedure, patients’ skin phototype and underlying

psychosocial disturbances should be considered.

Choosing the appropriate laser

In most practices, the choice of device depends on

what is available to the practitioner. When multiple

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

area of involvement and the presence of scarring. For

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

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

is generally too time-consuming and painful for the

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

therapy with or without δ-aminolevulinic acid can be

used. In cases of significant acne scarring, infrared

lasers are often used, since these devices are also fre-

quently employed to improve the texture of the skin,

including scars.The ultimate decision, however, is up

to the individual practitioner and the patient, and

should be evaluated in terms of what the treatment is

targeting: the sebaceous gland or P. acnes itself.

TARGETING P.ACNES

P. acnes produces and accumulates endogenous por-

phyrins, namely protoporphyrin, uroporphyrin, and

coproporphyrin III,20,21

as part of its normal metabolic

and reproductive processes. These porphyrins absorb

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

regions of the spectrum, and can be visualized by

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

fluoresce coral red.22

Porphyrins have two main absorption peaks, the Soret

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

which make them susceptible to excitation by lasers and

Lasers, light, and acne 71


light sources emitting wavelengths in the visible light

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

these photosensitizers generate highly reactive free-

radical species, which cause bacterial destruction23,24

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

a potent oxidizer that destroys lipids in the cell wall of

P. acnes.Although absorption and photodynamic excita-

tion are most efficient between the wavelengths of 400

and 430 nm, with enough light, the reaction may be ini-

tiated with a variety of different wavelengths.

Porphyrin concentration, effective fluence, wavelength

of the emitted photons, and temperature at which

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

photoinactivation.25

Photoinactivation of P.acnes with

visible light

UVA/UVB

After sunlight exposure, as many as 70% of patients

report improvement in their acne.26

It is not known

whether the UV or visible light component is primarily


400 600

Wavelength (nm)

Extinctioncoefficient

Soret band

Q-bands

> 2×105

L mol−1 cm−1

NH

Photons

N

N

Basic porphyrin structure

HN

Destruction of lipidsin cell wall of P. acnes

Reactive oxygenfree radicals

Excited porphyrin molecules

Fig. 7.2 Excitation spectrum of protoporphyrins.The Soret

band represents the highest peak of light absorption and thus

sensitizer activation, while the Q-bands represent the several

weaker absorptions at longer wavelengths. Because the

highest peak of absorption of porphyrins is on the blue

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

source systems for acne treatment.

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

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

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


responsible for this effect. In vitro experiments have

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

UV radiation; however, given the potential carcino-

genicity of UVA and UVB therapy, in vivo studies have

not been able to justify this means of acne treatment,

regardless of the treatment parameters.27,28

Conclusion: While anecdotal evidence of acne

improvement over the summer has a rational basis, the

potential side-effects of prolonged UV radiation are

unacceptable risks, and other modalities should be

sought.

Blue light

The strongest porphyrin photoexcitation coefficient

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

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

blue light (415 nm) leads to bacterial destruction.

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

four orders of magnitude 120 minutes after exposure

to a metal halide lamp with a wavelength of

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

CA). Kawada et al29

used this light source on mild to

moderate acne lesions in 30 patients and found a 64%

mean acne lesion count reduction after 10 Clearlight

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

order decrease in P. acnes colony count in correlated in

vitro experiments.The study showed that papules and

pustules improved more than comedones, but 10% of

patients actually experienced an increase in acne.

Another study utilizing the blue light source failed to

show bacterial count changes by polymerase chain

reaction (PCR) after therapy; however, damaged

P. acnes were observed at the ultrastructural level.30

Shalita et al31

used the ClearLight to treat 35 patients

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

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

an 80% improvement of noninflammatory and a 70%

improvement of inflammatory lesions as assessed 2 weeks

after the last treatment. Using the same device, Elman

et al32

carried out a split-face double-blind controlled

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

eight times for 15 minutes (420 nm, 90 mW/cm2). In

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

reduction of inflammatory acne lesions with a 60% mean

reduction of lesions in responders that remained steady at

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

et al32

treated 10 patients with papulopustular acne in a

split-face dose-response study, exposing them to

narrowband visible blue light (90 mW/cm2) for either 8

minutes or 12 minutes. Although there was a more than

50% decrease in inflammatory lesions in 83% of the

treatment areas, there was little difference between

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

versus 67.6%, respectively).32

Success in the treatment of acne vulgaris with the

blue light may be dependent on the lesion morphol-

ogy. For example, Tzung et al33

showed a 60%

improvement in papulopustular lesions in skin photo-

types III and IV with four biweekly treatments (F-36

W/Blue V, Waldmann, Villingen-Schwenningen,

Germany) and worsening of nodulocystic acne in 20%

of patients (n =28).

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

Pharmaceuticals, Inc.,Wilmington, MA), Gold et al34

found an average 36% reduction in inflammatory acne

lesion counts after 4 weeks of biweekly 1000-second

light therapy sessions, compared with a 14% reduction

in patients using 1% clindamycin solution twice daily.

The authors of this study, however, acknowledge that a

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

the clindamycin arm and n=12 for the light therapy

arm), making it difficult to draw a conclusion regard-

ing diligent topical antibiotic use versus blue light

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

study are considered, there is no difference in the

amount of clearing.

Conclusion: Blue light is effective for papules and

pustules more than comedones, and carries the risk of

worsening nodulocystic acne. It is effective in varying

skin types.

Combination blue and red light

One of the main restraints of blue light therapy for

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

penetrates poorly. Red light, while less effective in

photoactivating porphyrins,35

has increased depth of

penetration into the epidermis to reach the porphyrins

in the sebaceous follicles. Red light can also potentially

induce anti-inflammatory effects by stimulating

cytokine release from macrophages.36



In combination, red and blue light may act synergis-

tically by exerting both antibacterial and anti-inflam-

matory effects. Papageorgiou et al37

compared the

simultaneous use of red and blue light to treat acne

vulgaris in a randomized single-blind control study

with blue light phototherapy versus 5% benzoyl per-

oxide in a total of 140 patients with mild to moderate

acne. After 84 consecutive treatments of 15 minutes

(cumulative doses 320 J/cm2

for blue light and

202 J/cm2

for red light), the authors noted a final

improvement of 76% in inflammatory lesions, which

was significant compared with the results of blue light

or benzoyl peroxide alone.

Conclusion: Combination blue and red light may

act synergistically; however, the length of treatment

requires patient compliance and diligence.

Yellow light

Intense yellow light at 585 nm theoretically penetrates

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

P. acnes porphyrin excitation, offers another alternative

to laser devices. Edwards et al38

studied 30 patients

with mild to moderate facial acne and exposed each

side of their face to 3.0, 1.5, or 0.1 J/cm2

(sham)

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

of therapy, patients who received 3.0 J/cm2

had a 23%

improvement in Leeds acne score, with a 21%

decrease in total lesion count. This system relies on a

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

to patients with mild acne.

Conclusion: Intense yellow light may improve mild

acne, although alternatives exist in the blue light and

combined blue and red light modalities that have shown

greater efficacy than yellow light alone. Long-term

efficacy data are not yet available for the LED.


Intense pulsed light sources emit a broad band of light

with wavelengths generally ranging from 500 to

1200 nm. Although less selective by nature, these

devices emit wavelengths of energy that are absorbed

by many chromophores and therefore can be used to

treat a variety of conditions. The Palomar LuxVO

(Palomar Co., Burlington, MA) handpiece provides

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

et al39

studied this device in 15 patients with

Fitzpatrick skin phototypes I–V. Each patient received

three to five treatments spaced 1–2 weeks apart

(11 J/cm2, 60–100 ms pulse width, and three to four

passes over the entire treatment area) and was fol-

lowed up 3 months after completion of the last treat-

ment. The authors found no significant difference in

noninflammatory lesion counts, but did note a signifi-

cant reduction in mean comedone, papule, and pustule

counts as well as a significant improvement in global

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

crusting associated with postinflammatory hyperpig-

mentation was noted, but resolved with time.

Conclusion: IPL may be an effective and safe treat-

ment option for mild to moderate inflammatory acne

lesions in a variety of skin types.

Pulsed light and heat

Knowing that porphyrins have the highest excitation

spectrum at lower wavelengths and yet in order

to reach P. acnes a greater depth of penetration is

required, which can only be accomplished through

longer wavelengths, one of the dilemmas of light-

based therapy for acne vulgaris was how to combine

these two properties. As a result, Radiancy Inc.

designed proprietary technology for the simultaneous

delivery of pulsed light and heat energy (LHE) through

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

3–9 J/cm2, and spot size 22 mm × 55 mm).The LHE

technology primarily rests on the principle that, like

any other photochemical reaction, the efficiency of

porphyrin induced P. acnes destruction is determined

by the rate of production of excited porphyrins. The

rate of porphyrin excitation is related to four factors:

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

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

(4) the wavelength of the photons.40

One of the advantages of a pulsed light source com-

pared with continuous-wave mode devices is the abil-

ity to provide many more photons at peak power.41

For



example, a 3.5 J/cm2

pulsed wave light source with a

35 ms pulse width delivers 10 000 times more photons

than a continuous-wave 10 mW/cm2

light source.The

disadvantage of using pulsed light is oxygen (rate-

limiting) depletion and therefore rapid reaction satu-

ration. Because the range of emitted wavelengths

emitted by this device is broad, both antibacterial and

anti-inflammatory effects are induced, since the peak

absorption of endogenous porphyrins is covered as

well as that of hemoglobin in blood vessels proximal to

the inflamed acne papule.

The efficacy of a combination of heat and light is also

quantitatively justified through the Arrhenius equa-

tion, which states that the higher the temperature, the

faster a given chemical reaction will proceed.42

Thus,

the ability to deposit heat through conduction from a

nonoptical, exogenous source may reduce inflamma-

tion and even speed up the photodynamic reactions.

This was shown by Kjeldstad et al,23

who, using

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

inactivation of P. acnes increased as the temperature

increased in intervals of 10°C, 20

°C, and 37

°C, with

reciprocal increase in P. acnes colonies with decreased

temperature.

Elman and Lask43

studied the efficacy of the

ClearTouch system (Radiancy Inc., Orangeburg, NY)

in 19 acne treatment-naive patients with inflammatory

and noninflammatory acne lesions. Each patient

received a total of eight 10-minute treatments (two

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

3.5 J/cm2, 35 ms pulse, and 22 mm × 55 mm spot

size). One month after treatment, noninflammatory

acne lesions were 79% ± 22% clear, while inflamma-

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

the last treatment, noninflammatory and inflammatory

lesion counts were reduced by 85% and 87%, respec-

tively. Gregory et al44

also studied the ClearTouch

system in a multicenter blinded control trial of 50

patients suffering from mild to severe acne who dis-

continued all treatment 4 weeks prior to the start of

the trial. Patients served as their own control and

received two passes biweekly for 1 month. Four weeks

later, the authors noted a mean 60% reduction in

inflammatory lesion counts, compared with a 32%

increase in the control phase, with erythema as the

only reported side-effect (Fig. 7.4).

Conclusion:The technological basis of pulsed light and

heat makes intuitive sense by allowing practitioners to

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

this device is successful in treating both inflammatory

and noninflammatory acne vulgaris.

Laser

532 nm KTP laser

The 532 nm (green) potassium titanyl phosphate

(KTP) laser has as its target chromophores oxyhemo-

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

telangiectasia and superficial pigmented lesions.

However, since this laser has a greater optical penetra-

tion depth into skin than blue light, it has the innate


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

and 1100 nm in pulses of 35 ms and a low fluence (3–7.5J/cm2).This system,which combines light and heat damage to allow for

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

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

a b


ability to activate bacterial porphyrins along with

some nonspecific collateral thermal injury to seba-

ceous glands, and is generally well tolerated. Thus, it

has also been trialed in the treatment of acne vulgaris.

Baugh and Kucaba45

studied the effect of the Aura

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

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

center prospective trial. Patients who had been treated

with systemic antibiotics in the 8 weeks prior, topical

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

months prior to the start of the trial were excluded.

Individual pulses of 12 J/cm2

with a 30–40 ms pulse

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

use of a continuous contact cooling tip (Laserscope

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

for 2 weeks.The control area was treated with contact

cooling alone. Results demonstrated the greatest

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

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

reduction, with no improvement in infiltrated lesions

at 4 weeks. Acne pustules showed the most improve-

ment at 4 weeks, while comedone improvement did

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

treatment.Total percent improvement in comedones,

papules, pustules and infiltrated lesions was 25% 1

week after treatment and 21% 4 weeks after treat-

ment. Subjectively, 47.6% of patients felt 70–79%

overall satisfaction with the therapy. Of note, none of

the subjects experienced post-treatment redness or

irritation.

Using the Aura (Iridex, Mountainview, CA) KTP

laser (4 mm spot size, 7–9 J/cm2, 20 ms pulse, and

3–5 Hz), Bowes et al46

carried out a prospective split-

face study involving 11 patients using 6–10 passes per

half-face for 2 weeks. A moderate decrease in mild to

moderate acne lesion count was noted after 1 month

(36%), versus a 1.8% increase in the control group.

Sebum production also decreased (28%), but there

was minimal effect on P. acnes as measured by fluores-

cence photography.

Subsequently, Lee47

reported on her experience

with the Aura for facial and trunk acne by treating 25

patients with KTP alone, 25 patients with laser

followed by topical medications and cleansers, and

125 patients with concomitant laser and topical treat-

ment. A majority (90%) of the 125 patients treated

simultaneously with laser and topical agents had

80–95% improvement, which was similar to the

group who followed their laser treatment with topical

agents. Fifty percent of the 125 patients maintained

results over 4 months without additional treatment.

The laser-only group had more flares, less clearance,

and slower response times in comparison. These data

suggest that although the laser alone induces a limited

response, it may be beneficial in combination therapy

for acne treatment.

Conclusion: The KTP 532 nm laser can induce a

reduction in inflammatory facial acne, although long-

term suppression is variable.This laser is less successful

in comedone treatment, and may be best used as an

adjunctive therapeutic with topicals.

Pulsed dye laser: 585 nm

Similar to the KTP, the chromophore for the flash-

lamp-pumped pulsed dye laser (PDL) is oxyhemoglo-

bin, making it particularly suitable for reducing the

‘red’ component of clinically apparent acne lesions. In

addition, as discussed earlier, 585 and 595 nm yellow

light can be used to photoexcite porphyrins and

reduce P. acnes.

Seaton et al48

demonstrated a 49% reduction in

inflammatory lesion counts (regardless of severity

at baseline) versus 10% in controls 12 weeks after a

single pass of the 585 nm PDL (5 mm spot size,

1.5–3.0 J/cm2, and 350 µs pulse; NLite System, ICN

Pharmaceuticals Inc., Costa Mesa, CA). Other studies

using the same device, however, were less encouraging.

In a randomized blinded placebo-controlled trial of 26

patients with mild to moderate acne, Orringer et al49

showed only a trend towards improvement that was

not statistically significant in mean papule counts,

mean pustule counts, or mean comedone counts.

Grading of serial photographs also showed no signifi-

cant differences in Leeds scores for treated skin at

baseline and at week 12 compared with untreated skin

at the same time points.49

Although the two groups of

investigators used the same device setting, the number

of laser pulses used to treat each patient varied.

Orringer et al48

used 385 per patient, while Seaton



et al50

used at least 500 pulses per patient, which may

contribute in part to the difference in results.

Pulsed dye laser: 595 nm

Alam et al51

reported significant acne clearance in 25

subjects using a 595 nm PDL (7 mm spot size,

8–9 J/cm2, 6 ms pulse). These treatment parameters

may be more suitable for acne, given the increased

depth of penetration as well as longer pulse duration

and higher fluence (Fig. 7.5).

Conclusion: Because the pulsed dye laser is able to

affect the ‘red’ component of acne and has a good depth

of penetration, it may be suitable for patients with mild-

to-moderate inflammatory acne. However, the results

have been widely variable – from no improvement to

near 50% reduction.

In summary: targeting

P.acnes

The modalities thus far discussed directly or indi-

rectly rely on the biological property of porphyrin as

a photosensitizer to induce the destruction of P. acnes

colonies in vivo and clinically improve acne vulgaris.

Although light therapy in the 400–420 nm range

coincides with porphyrin peak excitation, longer

wavelengths allow for deeper dermal penetration.

Unfortunately, since P. acnes is a rapid regenerator,

acne clearance is generally short-lived (at most 3

months), and therefore treatments must be contin-

ued on an ongoing basis. Given this limitation, it is

questionable whether these laser and light-based

systems are a significant enough improvement over

topical therapies to justify the expense and time

needed to treat.


Fig.7.5 a) Patient with acne and post acne erythema before treatment. b) Same patient 6 weeks later, following two treatments

with the pulsed-dye laser.

a b


TARGETING THE

PILOSEBACEOUS UNIT

The sebaceous gland is under many influences during

adolescence.The ensuing increase in sebum production

plays a primary role in acne formation.Although target-

ing P.acnes is one approach to ameliorating acne vulgaris,

another involves targeting the pilosebaceous unit itself.

By reducing the size, and therefore the sebum output, of

the gland, or by straightening out the tubule by which it

drains, several devices have been shown to significantly

reduce acne for extended periods of time.

Photodynamic Therapy

Photodynamic therapy (PDT) has recently been used in

the treatment of acne vulgaris. This method uses a

photosensitizer and low-intensity visible light that,

together, produce cytotoxic oxygen radicals. One of the

advantages of this method is that the photosensitizer can

be selectively applied and illumination can be focused.

In addition, this system is equally effective on all strains

of P.acnes, regardless of antibiotic resistance.52

δ-Aminolevulinic acid

Topical δ-aminolevulinic acid (ALA) is preferentially

taken up by pilosebaceous units and incorporated

into the heme synthesis pathway, resulting in the pro-

duction of protoporphyrin IX.When photoactivated,

protoporphyrin IX produces singlet oxygen molecules

and free radicals, which are cytotoxic (Fig. 7.6). In

addition, it has been shown that the addition of ALA

actually enhances intracellular porphyrin synthesis

itself.53

PDT has also been used in combination with ALA in

the treatment of nonmelanoma skin cancer, actinic

keratoses, acne vulgaris, viral warts, and other der-

matoses.54

The combination of topical ALA applica-

tion followed by PDT results in cytotoxic free-radical

production and death of P. acnes, as well as damage to

the pilosebaceous unit itself. ALA application times as

brief as 15–60 minutes followed by red, blue, or

intense pulsed light, PDL, diode lasers, or LED

sources have all been shown to be effective.

ALA and red light

In a study of 22 patients with chest and back acne,

Hongcharu et al55

found that the majority of protopor-

phyrin IX production was localized in the sebaceous

glands and hair follicles after three hours application of

ALA under occlusion. Subsequently, these authors

used a broad band 550–700 nm red light source at a

fluence of 150 J/cm2, and were able to show a persis-

tent decrease in acne lesion counts for 10–20 months

following one to four treatments. Histology revealed

damaged and even destroyed sebaceous glands. Sebum

excretion rate, sebaceous gland size, and follicular

bacterial counts also all decreased. Adverse effects,

often typical of ALA–PDT treatment, included ery-

thema, crusting, pain, and hyperpigmentation. Itoh

et al56

reported an intractable case of acne vulgaris on

the face that, after treatment with ALA–PDT (4-hour

drug incubation, 635 nm), remained clear at 8-month

follow-up. A subsequent study by the same group57


Fig. 7.6 Devices using topical application of δ-aminolevulinic acid (ALA) are effective because they take advantage of the

heme synthesis pathway, leading to protoporphyrin IX.When the protoporphyrin IX is photoactivated, the singlet oxygen and free

radicals produced are not only cytotoxic to P. acnes but also damage the pilosebaceous unit itself.

Glycine + Succinyl CoA → ALA → Prophobilinogen → Hydoxymethylbilane →

Uroporphyrinogen III → (Uroporphyrinogen) III → Protoporphyrinogen III →

Protoporphyrin IX → Heme

↑

Ferrochelatase


evaluated 13 subjects and demonstrated a reduction in

new acne lesion counts at 1, 3, and 6 months following

PDT treatment.

ALA and blue light

Pain-free treatments with few side-effects have been

described with four weekly treatments using the blue

light after short ALA incubation periods (15 min-

utes).58

In 15 patients with moderate to severe acne,

the combination of 1-hour ALA incubation and blue

light led to a continued reduction in acne lesion counts

in responders up to 72% at 3 months after the last

treatment.59

ALA and red light diode laser

Pollock et al60

investigated the use of a red light diode

laser (CeramOptec GmbH, Bonn, Germany) in com-

bination with 20% ALA cream applied under occlu-

sion for 3 hours. Ten patients with mild to moderate

acne of the back were treated weekly for 3 weeks

(635 nm, 25 mW/cm2, and 15 J/cm

2) and assessed 3

weeks after the last treatment. ALA–PDT-treated

areas demonstrated a significant reduction in acne

lesion counts, but not in P. acnes concentration as

assessed by P. acnes swabs or sebum excretion. It is

possible, as Pollock et al60

suggest, that another mech-

anism of action may play a role in the response of acne

to ALA–PDT. They also suggest that perhaps PDT,

rather than destroying P. acnes, damages the bacterium

so that it is unable to function normally.They speculate

that when the bacterium is swabbed and put into an ideal

culture environment, it grows normally, thus giving an

inaccurate picture of what is occurring deep in the

pilosebaceous unit.

ALA and polychromatic visible light

Oral ALA followed by exposure to polychromatic

visible light from a metal halide lamp resulted in

marked improvement based on a physician clinical

assessment score in 61% of 51 patients treated for

intractable acne on the body. Kimura et al61

adminis-

tered the ALA at a dose of 10 mg/kg, which produced

no liver dysfunction. However, adverse effects did

occur, and consisted of slight discomfort, burning and

stinging during the irradiation.

ALA and IPL

Hwang and Seo62

compared two light spectra of IPL

(Ellipse, DDD, Denmark), namely VL (555–950 nm)

and HR (600–950 nm) with varying application times of

ALA (1 hour vs 4 hours).They followed patients at 1, 4,

14 and 24 weeks after a single treatment, and found no

difference in the number of comedones or inflammatory

acne lesions when comparing 1-hour and 4-hour ALA

incubation times. Of the two, the 600–950 nm applica-

tor was more efficient than the 555–950 nm applicator

in reduction of inflammatory acne. Given these data, and

the risk of hyperpigmentation, Hwang and Seo62

con-

cluded that ALA should be applied for a short time. Gold

et al54

enrolled 15 patients who underwent four weekly

treatments (ClearTouch, 3–9 J/cm2) after 1 hour incu-

bation with ALA, and found a 71.8% reduction in

inflammatory acne lesions at 12-week follow-up in 80%

of the patients.This was an increase from a 68.5% reduc-

tion 1 month after treatment. Of note, none of the

treated lesions recurred at 3-month follow-up.

ALA and PDL

In one of the few studies using patients with mild

to severe acne including cystic and inflammatory

lesions, Alexiades-Armenakas63

used a combination of

ALA–PDT with the 595 nm PDL. Topical ALA was

applied for 45 minutes on the face, followed by a single

minimally overlapping pass with the long-pulsed PDL

(595 nm, 7–7.5 J/cm2, 10 ms, 10 mm spot size, and

dynamic cooling spray 30 ms) in 14 patients, who were

then followed monthly for 13 months. Controls were

treated with conventional therapy (oral antibiotics,

oral contraceptives, or topicals) or PDL only.

Complete clearance occurred in 100% of the patients

in the PDL–PDT-treated group, with a mean of 2.9

treatments being required to achieve complete clear-

ance. In the control groups, mean percent lesional

clearance rate per treatment was 77%. The mean

percent lesional clearance per treatment was 32% in

the PDL-only group and 20% in the oral antibiotic and

topical group, although the number of patients in these

two control groups was small (n = 2 for each).

Nonetheless, the PDT–laser combination was well

tolerated, with minimal erythema lasting 1–2 days

without evidence of crusting, blistering, or dyspig-

mentation. This pilot study demonstrated that PDL



may be an efficacious combination with ALA to

achieve clearance in patients with varying stages of

acne from comedones to cysts.

Conclusion: Topical ALA application enhances the

production of porphyrins and not only can induce cyto-

toxic effects on P. acnes but can also target sebaceous

glands for destruction. The end-result is a decrease in

acne, which varies depending on the light source used

for illumination.

Indocyanine green

Carotenoids are the natural chromophore in sebum,

with an absorption range of 425–550 nm.The problem

with using a laser in this wavelength range is the number

of unintended components of the skin that will absorb

this wavelength, resulting in unwanted side-effects such

as blood coagulation.The ideal wavelength to use is in

the ‘optical window’, which is 600–1300 nm.64

The

only barrier is that local chromophores do not absorb in

this wavelength. However, indocyanine green (ICG, a

tricarbocyanine dye) is a chromophore with peak

absorption at 805 nm, which can be applied topically

and is known to be preferentially accumulated by seba-

ceous glands. In combination with diode lasers, ICG is

thought to cause both photodynamic and photothermal

effects within P.acnes and the pilosebaceous unit.

Tuchin et al65

treated 22 patients with inflammatory

acne lesions on the back and face. An 803 nm

(OPC-BO15-MMM-FCTS diode laser, Opto Power

Corp., Tucson, AZ) or 809 nm (Palomar Medical

Technologies, Inc., Burlington, MA) diode laser was

used after occlusive ICG application for 5 or 15

minutes.The combination of ICG and laser produced

less inflammation, lesion flattening, and reduction in

P.acnes and sebum production compared with no treat-

ment, ICG alone, and laser-only-treated areas. A sub-

sequent pilot study for moderate to severe acne lesions

showed that multiple treatments with ICG and a near-

infrared diode laser improved skin for as long as 1

month without side-effects when compared with a sin-

gle ICG-laser treatment session.66

In one of the select studies to look at body acne, Lloyd

and Mirkov67

treated patients with 5% ICG microemul-

sion for 24 hours under occlusion and then treated them

with a 810 nm diode laser (4 mm spot size, 810 nm,

40 J/cm2, and 50 ms pulse; Cyanosure, Inc.). Histology

showed evidence of selective necrosis of the sebaceous

glands. Using these parameters, the group then treated

10 patients with back acne, and their preliminary clinical

results showed a decrease in acne in the treatment area at

3-, 6-, and 10-month follow-up. It should be noted that

treatment did not lead to immediate resolution of acne

lesions, which cleared through the skin’s own healing

process. However, the treated regions remained lesion-

free for extended periods of time, leading Lloyd and


Laser pulse

Thermal injury to thesebaceous gland

Laser penetrates theskin to base of thesebaceous gland

Dynamic cooling devicepulse cools and protects

the epidermis

Dynamic cooling device spray

Sebaceous gland

Dermis

EpidermisStratum corneum

Hairfollicle

Sebaceous gland

Fig.7.7 Lasers at 1320,1450,and 1540 nm (mid-infrared) have shown impressive clearing of acne lesions.The lasers heat the

dermis, in bulk, including the upper and mid-dermis,where sebaceous glands are primarily located.As a result,a potential reduction in

the size and sebum output of the sebaceous gland,or a straightening of the infrainfundibular tubule,occurs and there is an

improvement in acne.Side-effects associated with these lasers are pain, transient erythema and edema,and a risk of hyperpigmentation.


Mirkov67

to speculate that ICG-diode laser treatment did

cause thermal damage in the sebaceous gland.

Conclusion: ICG and long-pulsed diode lasers are an

effective way to target sebaceous glands by applying an

exogenous chromophore to the skin, however down-

sides include incubation time and pain during treatment

due to collateral heating.

Infrared lasers

Isotretinoin use is known to cause shrinkage of seba-

ceous glands, with a resultant reduction in sebum

output. Interestingly, although sebum concentration

returns to normal after therapy discontinuation, many

patients remain clear of acne. This has led to the

hypothesis that even a temporary alteration of seba-

ceous glands may be sufficient to induce long-term

acne clearance.The distribution of sebaceous glands is

highly variable in the dermis; however, infrared lasers

target water, which is the dominant chromophore in

the sebaceous gland. Consequently, mid-infrared laser

light, which has a depth of penetration into the super-

ficial dermis, is able to produce a zone of injury in the

superficial dermal layer that may injure sebocytes and

arrest the overproduction of sebum and disrupt the

pathogenesis of acne itself. Alternatively, infrared

lasers may be affecting the infundibulum of the pilose-

baceous unit and improving the sebum flow out of the

gland (Fig. 7.7). In any event, infrared lasers have been

shown to significantly clear acne for extended periods

of time (Fig. 7.8). Infrared lasers encompass the 1320,

1450 and 1540 nm wavelength devices.

1450 nm

In a multipart trial, Paithankar et al68

demonstrated that

the 1450 nm diode laser with cryogen spray cooling


Fig.7.8 a) Patient with severe acne and acne scarring prior to laser treatment. b) Same patient 6 weeks later, following five

treatments with a 595 nm pulsed-dye laser and 1450 nm infrared divide laser (Smoothbeam Laser,Candela Corp.,Wayland MA).

a b


(Smoothbeam, Candela Corp., Wayland, MA) could

induce thermal injury confined to the dermis histologi-

cally after irradiation of ex vivo human skin. Using rabbit

ear skin as an in vivo model, treatment with the

Smoothbeam produced histological alteration of seba-

ceous glands within the dermis at day 1 and day 3, with

recovery from initial injury by day 7. Next, Paithankar

et al68

conducted a human trial, using the 1450 nm diode

laser (average fluence 18 J/cm2) for four treatments sep-

arated by 3 weeks each, and demonstrated a reduction of

acne lesions in 14 of 15 patients at 6-month follow-up.

Importantly, only 1 of the immediate post-treatment

biopsies yielded sebaceous glands, indicating that selec-

tive targeting of the sebaceous gland is possible, as the

histology demonstrated thermal coagulation of the seba-

ceous lobule and follicle with no epidermal alteration.

Long-term biopsies taken at 2 and 6 months post treat-

ment showed sebaceous glands that had returned to their

pretreatment state.

In a blinded multicenter study, 45 patients received

four monthly treatments with the 1450 nm diode laser

(14 J/cm2), of whom 26 had at least 65% improvement

in lesion counts 1 month following treatment.69

At 6

months, 5 patients required no additional intervention.

Mazer and Fayard70

reported 18-month remission rates

in 29 patients who avoided any additional acne-modify-

ing treatments such as laser or topical or oral therapy

after four treatments with the 1450 nm diode laser

(12–14 J/cm2, 35-dynamic cooling spray 35 ms, 6 mm

spot size, and no overlapping whole-face treatment)

every 4–6 weeks.They noted that initially there was an

average 74.8% reduction in total acne lesion counts

(maximum 88.5%, minimum 49.4%), which showed

only a slight deterioration to 71.8% at 18 months

(maximum 88.5%, minimum 47.9%).

A pilot study demonstrated the safety of the 1450 nm

laser in the treatment of inflammatory facial acne in 28

Indian patients with skin type IV or V.71

Each patient

was treated with four sessions at 21-day intervals, alter-

nating with glycolic acid peels on the 10th day after

laser treatment.The control group of 28 patients was

treated with glycolic acid peels only. The results

demonstrated a reduction in lesion count of 40% after

one treatment, 57% after two treatments, and 85%

after four treatments, with recurrence in 7.1% of the

group at 6 months. In comparison, lesion counts in the

control group decreased by 17.9% after one peel and

51.8% after four peels. However, 96.4% of the patients

in the control group experienced recurrence at 6

months. Postinflammatory hyperpigmentation was

seen in only 3.6% of patients. This low incidence of

postinflammatory hyperpigmentation may have been

due to the concomitant use of glycolic acid peels.

Jih et al72

compared the dose response of a 1450 nm

diode laser (prototype laser supplied by Candela

Corp.,Wayland, MA) in 20 patients with skin photo-

types II–VI and an age range of 18–39 years. Topical

lidocaine (5% Ela-Max) was applied to the entire face

1 hour before laser treatment, and patients were eval-

uated via split face comparisons after treatment with

either 14 or 16 J/cm2

for three treatments. At 12-

month follow-up, similar reductions in inflammatory

acne lesion counts were observed (76.1% reduction

using 14 J/cm2

vs 70.5% reduction using 16 J/cm2).

One of the downsides of 1450 nm diode treatment

is the level of discomfort reported by some patients.

As a result, widespread use of this laser in younger

populations has been limited. Bernstein73

reported his

experience in six subjects with active papular acne

who were treated in a split-face randomized trial

monthly for 4 months. Half of the face was treated

with a single pass (12–14 J/cm2), while the other half

was treated with a double-pass at a lower energy

(8 J/cm2), and subjects were evaluated 2 months after

the final treatment. Bernstein73

reports a 78% reduc-

tion in acne counts on the single-pass-treated side and

a 67% reduction on the half of the face treated with

the lower energy. Importantly, patients had an average

pain rating of 5.6 on a scale of 1 (minimum) to 10

(maximum) with the high-energy single pass and 1.3

with the lower-energy double pass.

The 1450 nm laser in combination with

other therapies

Using the 1450 nm laser as an adjunct in patients

who were on oral and/or topical acne treatments,

Friedman et al74

observed an 83% decrease in inflam-

matory facial acne lesion counts following three treat-

ments at 4- or 6-week intervals. Side-effects were

transient and local, including erythema, edema, and

pain during treatment. Similarly, Astner et al75

used

the SmoothBeam as an adjunct to conventional

acne therapy in 13 patients who continued their



medications during four treatments spaced 4–6 weeks

apart (12–14 J/cm2). They noted a mean 54.6%

improvement in lesions counts which persisted for the

6-month follow-up period of the study.

The 595 nm PDL has been used in combination with

the 1450 nm diode laser in a study of 15 patients with

inflammatory facial acne. First, patients were treated

with the 595 nm PDL (10 mm spot size, 6.5–7.5 J/cm2,

and 6–10 ms pulse; Vbeam, Candela Corp., Wayland,

MA) followed by a single pass with the 1450 nm diode

(6 mm spot size, 10–14 J/cm2, and dynamic cooling

spray at 30–40 ms). Glaich et al76

reported a mean acne

lesion count reduction of 52% after one treatment, 63%

after two treatments, and 84% after three treatments.

This combination may be successful due to the dual

targeting of the sebaceous gland (1450 nm laser) and

P.acnes (595 nm PDL) (Fig. 7.9).

Wang et al77

carried out a study in which 19

patients with Fitzpatrick skin types II–IV and active

inflammatory acne, who had discontinued all topical

and systemic anti-acne medications 3 weeks prior to

the first treatment and had not used isotretinoin in the

previous 6 months, were randomized and controlled

to receive a combination treatment on one side of the

face and laser only on the other side. Each patient

received a total of four treatments 3 weeks apart and

attended two follow-up visits at 6 and 12 weeks after

the last treatment. In those patients receiving combi-

nation therapy, one side of the face was treated with

microdermabrasion with six passes at the full setting

(Vibraderm, Dermatherm, Irving, TX). Following

this, the face was treated with the SmoothBeam

1450 nm laser (Candela Corp, MA; 13.5–14 J/cm2,

6 mm spot size, and dynamic cooling spray at

30–40 ms). Photographs of the patients at baseline and

at 3, 6, and 12 weeks post treatment were evaluated by

an independent observer, who counted the total num-

ber of acne lesions.Wang et al77

found no statistically


Fig.7.9 a) Patient with significant acne and acne scarring prior to treatment. b) Same patient 6 weeks later, following four

treatments with a 595 nm pulsed-dye laser and a 1450 nm infrared laser (Smoothbeam Laser,Candela Corp.,Wayland MA).

a b


significant difference in acne reduction with the

addition of microdermabrasion to the treatment plan

(61% clearance with laser alone and 54.4% clearance at

12 weeks for microdermabrasion and laser), nor was

there a significant difference in patient pain level or dis-

comfort. Interestingly, there was also no difference in

sebum production from baseline compared with 12

weeks post treatment.This is consistent with the notion

that thermal damage of the sebaceous glands immedi-

ately after treatment is quickly reversed.

Conclusion: Studies suggest that the 1450 nm diode

may have clinical utility as primary therapy for inflamma-

tory acne, or as an adjunctive acne treatment in patients

needing greater clearance than topicals or systemic

antibiotics alone can provide.

1540 nm

The 1540 nm erbium (Er) : glass laser (Aramis,

Quantel Medical, Med-Surge Technologies, Dallas,

TX), induces new collagen formation79,80

and has pri-

marily been used for wrinkle reduction. Studies by

Boineau and Kassir80,81

have shown success with this

laser wavelength in acne vulgaris as well.Twenty-five

patients with lesions on the back and face underwent

four treatments with the 1540 nm laser (10 J/cm2,

3 ms pulse, 5–6 pulse train mode, and 2 Hz) at

monthly intervals, and experienced a 78% mean

lesion count reduction.81

In a separate study evaluat-

ing the face only, 20 patients with skin phototypes

I–IV had an 82% decreased lesion count at 3 months

after four biweekly treatments (8–12 J/cm2

and 3–6

pulse train mode).82

An advantage of this system is the

decreased oiliness reported by patients in both trials

and the lack of immediate or delayed adverse effects.

Angel et al82

found a mean acne count reduction of

78% on 18 patients 2 years following treatment with

this device.

Conclusion: The 1540 nm Er : glass laser may be

appropriate for back and face acne in varying skin photo-

types, although only a few trials have been conducted

with this system.

1320 nm

Although no studies have been published on the

efficacy of the CoolTouch (Laser Aesthetics, Inc., CA)

1320 nm laser system in the treatment of acne, the

company was FDA-approved for this use in 2003.

Most of the studies involving the 1320 nm device have

evaluated its efficacy in acne scar remodeling.The der-

mal layer is targeted by using water as the primary

chromophore.The effect of dermal damage is collagen

remodeling and re-epithelialization, leading to a more

youthful-appearing epidermis.

Radiofrequency

Radiofrequency devices are used to treat moderate

and severe acne through volumetric heating. A hand-

held piece housing a treatment tip containing a coupler

allows for an even application of heat while a spray of

cryogen is delivered to avoid an epidermal burn; the

result is the creation of an inverted thermal gradient

such that the surface remains coolest while heat is

delivered to the dermis.

Ruiz-Esparza and Gomez83

used the ThermaCool

(Thermage, Inc., Hayward, CA) device and observed

an excellent response in 18 of 22 patients (82%), and a

modest response in 9%. Furthermore, they noted clin-

ical improvement in acne scarring.While these results

are encouraging, the limited follow-up time (1–8

months), and small study size (n = 22) underscore the

need for larger studies with longer follow-up.

Avram and Fitzpatrick84

compared the efficacy of

SmoothBeam and Thermage (Thermage, Inc.,

Hayward, CA) in alleviating both acne and acne scars.

Twenty patients with moderate acne (more than

eight inflammatory lesions) had half the face treated

with SmoothBeam (1450 nm and 12–16 J/cm2) and

the other half treated with Thermage (settings

13.5–15.0) during a total of three treatments spaced

4 weeks apart. At the 6-month post-treatment fol-

low-up, a 72% improvement in active acne on the

half-faces treated with SmoothBeam was found,

compared with a 60% improvement in the half-

faces treated with Thermage. However, Thermage

improved acne scarring by 46%, compared with 38%

with SmoothBeam. Ice pick scars were the worst

responders.



In summary: targeting the

pilosebaceous unit

In targeting the sebaceous gland, PDT, infrared lasers,

and radiofrequency devices are all effective to varying

degrees because they attempt to change a key link

in the chain of events leading to an acne lesion. In

theory, by damaging enlarged sebaceous glands, sebum

overproduction is decreased, if not eliminated, for a

period of time. As it stands now, however, this still

remains a theory, as only mild sebaceous gland alter-

ation has been proven histologically. Even though this

temporary alteration may be sufficient to result in

long-term acne clearance, studies have yet to demon-

strate sebaceous gland ablation. In those studies where

sebocyte alteration was evaluated, return to pretreat-

ment histology was noted in the long term. Further

studies are also needed to document histological

changes in the infundibular region that would improve

the flow of sebum from the gland.

FUTURE TRENDS

The idea of a portable handheld device to treat acne vul-

garis is becoming one of the emerging technologies in

laser and light based therapies.The Zeno (Tyrell, Inc.,

Houston,Texas, USA) was approved in June 2005 by the

FDA as an over-the-counter device for the treatment of

mild to moderate acne vulgaris, and is proposed to work

through the induction of heat-shock proteins, which

then kill resident P. acnes.85

No preliminary results

regarding the efficacy of this device have yet been pub-

lished; however, clinical trials are currently underway

and the product is available for consumer purchase.

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85. Retrieved from http://www.myzeno.com.



INTRODUCTION

Optimal treatment of acne scarring is prevention of

the same by aggressive treatment of active acne.1,2

Failing that, the treatment of acne scarring may require

the sequential application of several corrective proce-

dures. Even so, the degree of improvement is typi-

cally incomplete, as scar can be concealed but not

removed.

DEFINITION AND CLASSIFICATION

OF ACNE SCARS

Before appropriate therapies can be selected, acne scar-

ring needs to be qualitatively and quantitatively assessed.3,4

The simplest operational definition of acne scar is a visi-

ble textural abnormality that was historically preceded

by active acne at the same site, and if biopsied, would

reveal histological evidence of a scar. In practice, it may

be difficult to confidently assert the provenance of a

particular scar, since the active process – acne or some-

thing else – leading to its creation may be temporally

remote.Yet there are typical configurations of scarring

that are usually believed, based on visual inspection

alone, to be highly likely to have been caused by acne.

Acne scars can be classified based on shape and

depth. One recently proposed classification recognizes

three types of scars (Fig. 8.1):4

• ice-pick scars are V-shaped nicks with a pinpoint

base that may culminate in the shallow papillary

dermis or in the deep reticular dermis

• boxcar scars are rectangular scars with vertical

walls and a flat base, and these may also be shallow

or deep

• rolling scars are gently undulating scars that resem-

ble hills and valleys, are less well-demarcated, and

tend to be less focally deep

Alternatively, acne scars can be considered hyper-

trophic, atrophic, or a combination thereof:3,5

• grade 1 acne scarring is distinguished by erythema-

tous, hypopigmented, or hyperpigmented macules

(Fig. 8.2)

• grade 2 is distinguished by mild atrophy or hypertro-

phy, similar to the rolling scars described previously

• grade 3 is distinguished by moderate hypertrophy

or atrophy that is visible at social distances of 50 cm

or greater, and rolling and shallow box car scars, as

well as moderate hypertrophic and keloidal scars

• grade 4 is distinguished by severe atrophy or hyper-

trophy that cannot be flattened by stretching the

skin between thumb and forefinger

8. Treatment of acne scarring

Murad Alam and Greg Goodman

Fig 8.1 Stylized cross-sectional view of ice-pick, rolling,

shallow boxcar,and deep boxcar scars (from left to right).The

upper horizontal dashed line denotes the normal depth of

ablation with resurfacing procedures, the three lines in a

pyramidal array represent fibrous bands securing the rolling

scar to the dermal–subcutaneous junction. (Based on the acne

classification popularized by Jacob,Dover,and Kaminer.)


The classification of acne scarring as a function of indi-

vidual skin type is less well described. It is known that

some individuals are more prone to develop scarring

following resolution of acne papulopustules or cysts,

whereas others may only have transient erosions

or discoloration that eventually remits. In general,

patients who have previously developed acne scarring

remain at risk for further scarring following active

acne in the future. Acne scarring of equivalent depth

and type may also be more noticeable on patients with

darker skin types or pigmentary abnormality. For

instance, the light and shadow of darker skin may

accentuate the apparent depressions associated with

acne scarring; similarly, rosacea or centrofacial redness

may demarcate and define the borders of acne scars on

the cheeks.

AGE OF ACNE SCARS AND

ACTIVE ACNE

To some extent, the appropriate treatment for acne

scars is predicated on their age. Specifically, if scars are

red, a series of laser treatments with pulsed-dye laser

or intense pulsed light may be especially useful for

reducing this blush if the scars are not more than a few

years old.6,7

In cases when active acne has resolved

during the past 6–12 months, caution should be exer-

cised when approaching the treatment of scarring. It is

possible that the superficial resolution of acne may not

be indicative of a cessation of the deep process, and

invasive procedures such as subcision or resurfacing

may restimulate cyst formation.

It is essential to adequately treat and inactivate all

ongoing acne before treatment on any scarring can

commence.The presence of active acne strongly mili-

tates against the treatment of any coexisting acne

scars.These acne scars may either not be mature – and

hence may be susceptible to exacerbation or inflam-

mation – or mature themselves but their treatment

may trigger nearby active acne. An in-depth consulta-

tion with the patient is required to convey this con-

cern. It should be explained that the deferment of acne

scar treatment does not indicate reluctance to treat

acne scars or lack of expertise in such treatment;

rather, the postponement is necessary because imme-

diate treatment may worsen the combined adverse

visual effect and symptomatology of the active acne

and acne scarring. Active acne cysts may enlarge and

drain, or become painful, and the active acne inflamed

by manipulation may lead to further acne scarring.

A final caveat entails the treatment of acne scarring

in patients with pre-existing conditions that may lead

to poor scar healing. Such conditions may be managed

like acne scarring in the context of active acne: treat-

ment of the scars may be delayed or embarked upon

very gingerly so as to preclude inadvertent exacerba-

tion. Most authorities suggest that invasive procedures

for acne scarring be undertaken only 1 year after com-

pletion of oral isotretinoin treatment for resistant cys-

tic acne. A complete history should elicit information

about such treatment; the timing, type and degree of

success associated with prior acne scarring improve-

ment procedures; any tendency to produce keloids or

hypertrophic scars after surgery or injury; any ten-

dency to hyperpigment after injury; disorders, such as

collagen vascular diseases, that impede wound healing;

bleeding diatheses; disorders that predispose to infec-

tion; recurrent cold sores; allergies to antibiotics and

medications; and psychological disorders, including

depression, anxiety, factitial disorders (e.g., compulsive


Fig 8.2 Postinflammatory hyperpigmented macules of the

cheek after resolution of active acne.


picking, self-mutilation, etc.) and medication for these.

Picking behaviors are exceedingly common, especially

in young women who have an obsessive need to ensure

the perfection of their skin, and a consequent urge to

extirpate pimples and textural abnormalities with their

nails and other implements.The physician should care-

fully explain that picking after procedures to reduce

acne scarring will worsen this scarring and be highly

counterproductive. If the patient seems unable or

unwilling to grasp this concept, or appears unlikely to

to adhere to a postoperative regimen, expert consulta-

tion with a psychologist or psychiatrist is desirable

prior to proceeding with surgery.

PATHOGENESIS OF ACNE SCARRING

The pathogenesis of acne scarring is too complex an

issue to discuss fully here, but recent research indicates

that intensity of scarring may be associated with the

extent of inflammation associated with active acne.

Specifically, the type and timing of the cell-mediated

immune response may be associated with the degree of

post-acne scarring.8

In one study, the cellular infiltrate

and nonspecific immune response were initially greater

but later reduced in patients who did not subsequently

develop scars. However, in patients who did develop

post-acne scarring, the initially smaller specific immune

response later increased.

MANAGEMENT OF ACTIVE ACNE

If the patient does have active acne, a brief discussion

about treatment of acne scars should be followed by

implementation of a plan to stop the production of

new acne lesions. Treatment of active acne can take

12–18 months or more before a steady state of near-

clearance is reached. If prior measures to control

active acne have included the use of isotretinoin, a

minimum of 12 months and as much as 18 months

should elapse prior to treatment of acne scarring.

Once patients understand that treatment of active acne

is a necessary prerequisite for treatment of acne scar-

ring, they may be more compliant with acne treatment

than in the past.

Lack of new acne lesions for a few weeks or 1–2

months does not necessarily presage a remission of

active acne.This may simply be a cyclical or fortuitous

reduction in acne that may not persist. If some degree

of active acne remains persistent, continuing efforts to

manage this should continue even as invasive treat-

ments for acne scarring are commenced. Sometimes

patients will continue to develop one or two small

papules every few weeks even when on maximal ther-

apy for acne.At some point, after treatment with topi-

cal and oral antibiotics and retinoids, the surgeon may

have to decide to proceed with acne scarring treat-

ment despite the occasional occurrence of active acne.

TYPES OF TREATMENTS FOR ACNE

SCARRING: RESURFACING,

NONABLATIVE THERAPY,

INCISIONAL SURGERY, INJECTION,

CYTOTOXIC THERAPIES

The number and range of treatments for acne scarring

is vast. Indeed, the options are so plentiful that even

experienced practitioners need to group and classify

therapeutic options to simplify decision-making. One

grouping recognizes four major categories:

• treatments for altering the color of the acne mark

or scar

• excisional and incisional surgery, including most

punch techniques

• augmentation by autologous and nonautologous

methods

• treatments for increasing or decreasing collagen

deposition around the scar

The last method, which includes nonablative, partially

ablative, and ablative resurfacing by any means, sub-

sumes the largest number of discrete interventions.

Notably, since techniques within a given category are

similar in terms of invasiveness, downtime, risk, and

efficacy, practitioners may need to master only one or

two treatments per category to provide patients with a

complete range of therapeutic options. Finally, since

even the most invasive acne scarring treatments in the

hands of experienced physicians are unlikely to result

Treatment of acne scarring 91


in near-total resolution of scarring, a series of treat-

ments that work synergistically should be selected.

Some procedures are more risky and may be associ-

ated with delayed healing, and the practitioner should

determine the level of risk preferred by the patient. In

sum, for best outcomes, it is preferable to be (1)

expert at a few procedures rather than to be passably

familiar with a large number and (2) collaboratively

with the patient, develop a rational, sequential treat-

ment plan that cumulatively provides the best possible

outcome.

‘Resurfacing’ denotes treatments that entail removal

or destruction of the epidermis and partial-thickness

dermis. Subsequent to resurfacing procedures, dermal

and epidermal re-epithelialization occurs, usually over

a period of 1–2 weeks. Post treatment, there is a reduc-

tion in acne scars that occurred in the skin strata that

were resurfaced. Resurfacing is associated with risk of

hypopigmentation and scar, which can occur if the

depth of ablation reaches the bulge region of the hair

follicle. Common resurfacing procedures can rely on

thermal, chemical, or mechanical injury, and include

laser ablation, medium to deep chemical peels,

dermabrasion, and plasma resurfacing.

‘Nonablative’ therapies are those that do not fully de-

epithelialize the epidermis and dermis but rather deliver

subdestructive energies that induce skin remodeling.

Most commonly, nonablative therapies induce thermal

injury by application of a range of laser and light sources,

but other energy devices, such as bipolar and mono-

polar radiofrequency (RF), may be used.

Between resurfacing and nonablative therapies are

an intermediate set of treatments referred to as ‘par-

tially ablative’ or ‘minimally ablative’. Typically, these

create a penetrating epidermal and dermal injury only

over a small percentage of the treated skin surface

area. Downtime is consequently reduced over that of

resurfacing, but efficacy may be better than for non-

ablative treatments. Common examples of partially

ablative therapies are fractional resurfacing as well

as skin needling and rolling.

‘Incisional surgery’ entails cutting into the skin, and

may also include removal of skin, or excision. Pitting

or ‘ice-pick’ scarring can be treated by punch excision,

punch grafting, or punch elevation. Rolling scarring

can be improved by subcision: minute cuts in the skin

followed by abrasion of the underside of the dermis.

Large, mixed acne scarring in a linear array can be

removed by standard elliptical excision.

In some cases, the skin may be pierced but not cut as

pre-packaged injectable fillers or autologous fillers are

instilled under acne scars to raise them flush to the

skin. ‘Injection’ therapy for acne scars has advanced

since the introduction of a range of new soft-tissue

augmentation materials over the past decade. Such

materials include autologous fat, human collagen,

hyaluronic acid derivatives, calcium hydroxyapatite,

silicone, and other agents.

Cytotoxic therapies may be most relevant for hyper-

trophic acne scars. Either medical or radiation thera-

pies may be used to mitigate the growth of exuberant

scars on the chest, face, and back. Intralesional agents

such as 5-fluorouracil (5-Fu), bleomycin, and verapamil,

topical agents such as imiquimod, as well as radiation

treatment may help flatten scars.

ACNE SCAR TREATMENT BY

RESURFACING

Resurfacing is commonly accomplished by laser, chemi-

cal application, or dermabrasion.To some extent, the

choice of procedure is a function of the age of the

treating dermatologist, and prevailing fashions when

he or she trained.

Laser resurfacing remains a gold standard for safety

in ablative resurfacing. In this procedure, a carbon

dioxide (CO2), erbium : yttrium aluminum garnet (Er:

YAG), or hybrid laser device is used to vaporize the

epidermis and partial-thickness dermis.As a calibrated

laser is used, tissue removal is precise, reproducible,

and minimally operator-dependent; especially when a

computerized pattern generator (CPG) is used, even

and consistent skin removal is achieved.The CO2

laser

provides the deepest injury, some immediate tissue

contraction, hemostasis through its cauterizing effect,

and the overall best clinical effect achievable by laser,

but downtime with multiple-pass resurfacing can be

1–2 weeks. The Er:YAG laser is associated with less

invasive ablation that is more suited to the treatment of

fine acne scarring or photoaging, but downtime until

complete re-epithelialization can be half as long. Since

intraoperative bleeding can complicate and hence

limit multiple-pass Er:YAG laser resurfacing, some



hybrid devices include a small CO2

laser to facilitate

coagulation; alternatively, a low-power and high-

power Er:YAG laser can be paired in the same box for

this purpose. Hybrid devices may also provide a clini-

cal effect intermediate between classic Er:YAG and

CO2

laser resurfacing. Using an Er:YAG laser after

CO2

laser resurfacing can remove a thin layer of debris

and devitalized tissue, and speed healing. Notably,

post-treatment erythema after CO2

laser resurfacing

can last 2–3 months, although it can be concealed with

make-up. Outcome data indicate that most patients are

very pleased with the outcome of their laser resurfac-

ing procedure at 3 months post treatment, and remain

so at 18 months; in the immediate postoperative

period, the anxiety associated with wound-healing

and temporary disfigurement causes mild, transient

concern in some.9

In dermabrasion, the skin is smoothened by mechani-

cal abrasion analogous to sanding.The skin is scraped

away with a wire brush or a spinning disk-like burr

covered with diamond particles; in some cases, true

medium- or fine-grit sandpaper that has been auto-

claved and wrapped around the finger or instrument

like a thimble may be used to treat small areas.

Dermabrasion has become less popular since the advent

of HIV and other bloodborne infectious diseases that

can be spread by aerosolized particles of skin and blood.

Unlike laser resurfacing, dermabrasion is more opera-

tor-dependent, as the pressure applied can modify the

depth of treatment.Acquiring and maintaining adequate

anesthesia during dermabrasion can be challenging, and

certain areas, including the eyelids, nose, malar promi-

nence, and jawline, can be difficult to treat.There are no

controlled studies comparing laser resurfacing with der-

mabrasion for acne scarring, but in the anecdotal expe-

rience of the authors, laser resurfacing appears to be

more consistently efficacious. Dermabrasion may, how-

ever, be less prone to cause post-treatment erythema

than laser resurfacing. Hypopigmented macules associ-

ated with acne scars (Fig. 8.3) have in some cases been

reported to be improved following needle dermabra-

sion (using a tattoo gun without pigment) or focal

manual dermabrasion.10,11

Medium and deep chemical peels are another resur-

facing technique. Medium-depth peels typically consist

of sponge application of trichloroacetic acid (TCA),

20–35%, after degreasing of the skin; sometimes, a

prepeel with Jessner’s solution may be performed to

improve even peel penetration. Depending on the

duration of application and the number of layers of

solution, a deeper or shallower effect can be achieved.

The benefits of medium-depth peeling are that no

expensive machinery, such as a laser, is required. Also,

there is no aerosolization of infectious particles.At the

same time, peels are relatively operator-dependent,

and pooling of solution in facial crevices can result in

uneven treatment from less experienced practitioners.

In general, medium-depth peels provide a shallower

ablation than CO2

laser resurfacing. Deep chemical

peels, most notably the Baker–Gordon or phenol peel,

are deeper-penetrating but carry two potential risks:

(1) the potential cardiotoxicity of phenol requires

intraoperative monitoring during full-face peeling;

and (2) porcelain-white hypopigmentation will occur

after treatment. For patients with focal acne scarring

who always wear make-up, deep peels may be a safe

option due to the small surface area treated and the

ability to conceal depigmentation post-operatively. A

special localized case occurs when a toothpick, or the

sharp wooden end of a cotton-tip applicator created

after the applicator has been deliberately broken, is

dipped in a very concentrated solution of 95% or

100% TCA and then applied to the base of an ice-

pick scar. This resurfaces the pinpoint base of the

scar, and permits repair by granulation, which can fill

in the scar.12


Fig.8.3 Hypopigmented cheek scars that are slightly

atrophic.


A more recent variant of resurfacing is plasma resur-

facing.This uses the ‘fourth state of matter’ to precisely

injure epidermis and underlying dermis without induc-

ing immediate sloughing of the epidermis. As such,

plasma resurfacing has similarities to single-pass CO2

laser resurfacing.A plasma cloud of electrons removed

by radiofrequency sparking of nitrogen gas is absorbed

by the skin, but the epidermis is not truly ablated. In

process, it seems to resemble a medium-strength TCA

peel, but may give deeper and more impressive

results, seemingly without much risk of hypopigmen-

tation and scarring, although it is a comparatively new

technique. The gentler approach, and the persistence

of partially injured epidermis as a biological dressing,

minimizes fluid loss, crusting, and delayed healing.

Healing usually occurs within a week.

There are some similarities regardless of the resur-

facing technique used. Tumescent or local anesthetic,

combined with nerve blocks and at least oral sedation,

is usually employed. Beyond this, conscious sedation

or general anesthetic may be used, especially for laser

resurfacing. Post treatment, some method of dressing

(either closed or open) is used to protect the de-

epithelialized skin as it heals. For at least 1 week, the

patient cannot be present at work or social engage-

ments. In darker-skinned patients, post-inflammatory

hyperpigmentation is a virtual certainty; in Asian and

African-American patients, such color change may last

a year or longer before gradually resolving.The risk of

infection is mitigated by initiating oral antibiotics and

antivirals before the resurfacing procedure.


NONABLATIVE THERAPY

During the past 5 years or so, nonablative therapy has

largely replaced ablative therapy for the treatment of

acne scars. In nonablative therapy, directed energy,

usually thermal, is used to induce tissue modification

and collagen remodeling in the dermis. The benefits

compared with ablative therapy are that skin de-

epithelialization does not occur, and nonablative

therapy is therefore a ‘lunchtime’ procedure that is

associated with little or no downtime. Transient ery-

thema and mild edema resolving over hours to days

are often the only post-treatment effects. Since

nonablative therapy tends to be a milder procedure

than ablation, multiple treatments may be required

and/or these treatments may be combined with other

acne treatment methods.

Since heating of the dermis can induce remodeling of

the dermis and improvement of embedded acne scars,

a range of laser and light devices can be used. Indeed,

virtually any laser or light device, used appropriately,

can achieve modest improvement in acne scars.Among

those that have been used in this capacity are the

pulsed-dye laser, the potassium titanyl phosphate

(KTP) laser, and intense-pulsed light.These are vascu-

lar-selective machines that, apart from improving sur-

face topography, can also reduce the erythema that may

encircle and hence accentuate acne scars of the central

face. Multiple treatments, often 3–6 or more about a

month apart, are needed to reduce redness and cause

some textural change.

A class of nonablative lasers has been especially suc-

cessful at improving acne scars. These mid-infrared

lasers include the 1064 nm neodymium (Nd):YAG,13

1320 nm Nd:YAG (Cool Touch),14–18

1450 nm diode

(Smoothbeam),19

and 1540 nm Er:glass (Aramis), as

well as intense-pulsed light machines with a similar

range (Titan, 1100–1800 nm). Such devices have been

shown in numerous studies to significantly improve

rolling, boxcar, and ice-pick scars of the cheeks, peri-

oral areas, and elsewhere.The main limitation is intra-

operative discomfort, which may be sufficient to require

topical and oral pain medications. In darker-skinned

patients, the risk of postinflammatory hyperpigmenta-

tion is significant and may suggest the use of the

1540 nm device.

Nonablative therapy can also be performed with RF

devices, including those using monopolar and bipolar

technologies. RF energy, in cadaver skin, can shrink the

fibrous septae,20

and may also have collagen-remodeling

effects.While it is typically used for tightening sagging

facial or body skin rather than for rectification of acne

scars, RF treatment, like treatment with broadband

infrared light, may ameliorate acne scars.

When acne scars are mild, textural abnormality

may be minimal, and the primary visual feature may be a

halo of erythema that highlights the scar. Such redness

can be removed by a series of treatments with vascular-

selective lasers or light sources,21

such as the pulsed-dye

laser, the KTP laser, and the intense-pulsed light device.



Post-treatment effects are minimal erythema and

edema, which resolve within a few hours to a day. Such

treatments may be also appropriate for patients who

desire a very minimal intervention, and can tolerate

little or no downtime. Acne excoriée, which may be

associated with erythematous macules, has also been

successfully treated with vascular laser and psychother-

apy.22

It is believed that erythematous acne scars can be

treated even when they are immature, by pulsed-dye

laser immediately after suture removal.23

Unlike erythe-

matous macules, hyperpigmented and hypopigmented

macules are better managed passively. Q-switched lasers

for pigment and tattoos are minimally effective in reduc-

ing post-inflammatory hyperpigmentation, and may

even exacerabate such pigmentation at high fluences;24,25

gentle nonablative glycolic acid, salicylic acid, Jessner’s

solution, and retinoic acid peels may be less prone to

aggravate brown areas.26,27

In general, pigmentation of

scars in olive-skinned patients will fade gradually over

3–18 months, if strict sun avoidance and sun protection

are practiced in association with a topical preparation,

such as hydroquinone, kojic acid, and azelaic acid.28,29

White macules may be very difficult to treat, and may

only be transiently repigmented with repeated treat-

ments with the 308-nm excimer laser, phototherapy, or

application of autologous cultured melanocytes.

Microdermabrasion, a topical therapy that entails

spraying of aluminum oxide crystals on the epidermis,

is popular and frequently touted as beneficial for acne

scarring.30

However, objective evidence of the efficacy

of microdermabrasion for treatment of acne scarring

is minimal.What little improvement can be achieved

appears to require repeated, intense sessions and the

elicitation of pinpoint bleeding, which is seldom

induced. Microdermabrasion should not be confused

with dermabrasion, a highly effective ablative therapy

for acne scars.


PARTIALLY ABLATIVE THERAPY

For treatment of acne scars, resurfacing provides max-

imal improvement and nonablative therapy offers the

promise of convenience and safety. To wed these two

desirable outcomes in a single therapy, so-called ‘par-

tially ablative’ treatments have been devised. These

methods are used to resurface only a portion of the

skin area treated, thus allowing maintenance of skin

integrity, fewer side-effects, and more rapid healing.

One pioneering method of partially ablative therapy

is fractional resurfacing. Using a diode-pumped 1550 nm

erbium laser, fractional resurfacing (Fraxel, Reliant

Technologies, Mountain View, CA) creates a grid

pattern of microthermal zones of tissue coagulation

but an intact stratum corneum.31,32

Over a period of

days after treatment, microscopic epidermal and der-

mal necrotic debris is expelled, and collagen remodel-

ing occurs at the affected areas. A series of treatments

can resurface virtually the entire surface area, but by

fractionating treatments, downtime is minimized and

the serous crusting of typical resurfacing is avoided. It

has been shown that high-energy treatments are more

effective for the treatment of acne scarring; such treat-

ments do not ablate more surface area, but provide a

greater volume of thermal injury.

A simpler, less precise approach to partially ablative

therapy is skin rolling or needling. These procedures

purport to achieve on a macroscopic level what frac-

tional resurfacing can do on a microscopic level. In

needling,11

a fine 30-gauge needle held by a hemostat

is used to serially puncture a 2–3 mm deep grid pat-

tern on the skin, including epidermis and dermis.

Fibrous bands holding down acne scars are released,

and the coagulum resulting from the pinpoint intra-

dermal bleeding can raise depressed scars and instigate

granulation tissue. For larger scars, a tattoo gun with-

out pigment11

or a rolling pin may be used. Rolling is

performed with a needle-studded rolling pin33

– a

metal cylinder implanted with needle-like protrusions

– that is pressed against the facial or extrafacial skin

and rotated around the long axis to make an array of

microperforations until some bruising is observed. In

both rolling and needling, pinpoint bleeding occurs

and is managed by application of pressure. Epidermal

healing occurs with minimal crusting in a few days,

and dermal trauma culminates in collagen remodeling.

This process, also referred to as ‘collagen induction

therapy’ can be repeated a few weeks later.Anatomical

areas that respond poorly to this treatment include the

nose and periorbital regions. Synergies may accrue if

rolling is used in combination with other treatments,

such as nonablative laser, vascular laser, subcision, or

blood transfer.




INCISIONAL SURGERY

Apart from ablative, partially ablative, and nonablative

external smoothening techniques, cutting surgery can

be used to treat acne scars. One minimally invasive

surgical technique for rolling scars is subcision, which

is preceded by instillation at the site of scarring of

anesthesia – local for small areas and tumescent

for larger areas. Developed by Norman and David

Orentreich,34,35

subcision (Figs. 8.4 and 8.5) requires

insertion of an 18–26-gauge Nokor or similar needle,

or even a blunt canula, into the superficial subcutis.

Depth of insertion is contingent on the degree of scar

indentation, with intradermal positioning more appro-

priate for shallow scars and deep dermal placement for

deeper scars. The needle is then rotated so that the

spearlike tip is parallel to the skin, and the needle is

used to tent the skin. Back-and-forth rasping move-

ment of the needle along the underside of the dermis

releases fibrous attachments holding down scars and

stimulates the growth of reactive fibrosis that gradually

fills the deadspace underlying newly loosened scars. In

a manner similar to liposuction, fanning movement of

the needle and triangulation of each scar from differ-

ent entry sites helps elevate scars. Especially if wide-

spread treatment is being performed, intraoperative

bruising and bleeding is minimized by using tumescent

anesthesia, or copious quantities of a dilute 0.5% lido-

caine with 1:200 000 solution, and allowing the anes-

thesia to sit for 20–30 minutes before commencing


Fig.8.4 Rolling scars amenable to subcision can occur

periorally, on the upper and lower cheeks, and at the temples.

Subcision can also be highly effective for nasal scars (not

shown).

Fig.8.5 (a) In subcision, the rasping needle is used to

release the fibrous bands connecting rolling scars to the deep

skin structures. (b) Simultaneous tenting of the skin with the

needle minimizes the risk of injury to neurovascular

structures.

a

b


needle insertion. Postoperative ecchymoses and edema

can last 1–3 weeks.To avoid a flare of cystic acne after

treatment, susceptible patients with some active acne

may be treated with oral tetracyclines for several

weeks before and after subcision.

Individual deep boxcar or ice-pick scars can be resis-

tant to nonsurgical treatment. At times, the best

approach can be to cut these out.A time-honored tech-

nique uses a biopsy punch to treat such scars. If the

targeted scar fits precisely within the punch, circumfer-

ential cutting with the punch can cause elevation of the

scar as lateral and deep fibrous bands are severed and the

plug containing the scar spontaneously elevates.This is

referred to as punch elevation. Alternatively, if the scar

is very deep and well embedded, the central plug may

be removed, as in the case of a punch biopsy.Then the

created defect may either be sewn end-to-end, to create

a slit-like scar (i.e., punch excision), or filled with a sim-

ilar shaped plug harvested from an uninvolved scar (i.e.,

punch grafting). At times, a series of deep scars may be

present in a linear or curvilinear array. Such scars may

be revised by removal of a strip of epidermis and dermis

using the techniques of elliptical excision and bilayered

closure with eversion. If a patient requires punch or lin-

ear excision as well as resurfacing for treatment of acne

scars, it is preferable to perform the excisions first, as

the re-epithelialization following the ablative procedure

will conceal the excision lines.

Perifollicular hypopigmentation of acne scars, espe-

cially those of the trunk, remains highly resistant to

treatment. If papular and facial, hypopigmented scars

may be treated with fine-needle diathermy, and graft-

ing procedures useful in vitiligo may also be consid-

ered. Minigrafting is limited in efficacy, since the

spread in pigment from the graft sites to the surround-

ing scars appears to be restricted,36,37

but epidermal

suspensions of cultured and noncultured cells are

promising new therapies. Newly available automated

commercial kits for trypsin epidermal separation (Re-

Cell) may simplify the grafting process.37,38

ACNE SCAR TREATMENT BY FILLERS

Filler injection is a minimally invasive method of

scar improvement that can be combined with other

treatments. Also known as soft-tissue augmentation

materials, fillers can be autologous, heterologous, or

synthetic; additionally, they can be prepackaged or

harvested prior to use.

Until the 21st century, the primary Food and Drug

Administration (FDA)-approved prepackaged aug-

mentation material was bovine collagen. Since then,

human-derived collagen (Cosmoderm and Cosmoplast),

hyaluronic acid derivatives (Restylane, Juvederm,

Hylaform, Hylaform Plus, and Captique), calcium

hydroxyapatite (Radiesse – pending FDA approval,

used off-label), and liquid silicone (used off-label)39

have been used frequently (Table 8.1). While bovine

collagen required skin testing to exclude allergy,

none of the newer fillers do, although they should

not be used in patients with known sensitivity to their


Table 8.1 Common fillers for acne scarring (USA)

Filler type Filler name Method of use Persistence

Human-derived

Autologous Blood aspirate Can be injected deep or superficially Weeks to months

Fat Injected deep for rolling scars Weeks to months, portion of effect

may be permanent

Heterologous Human collagen Fine superficial scars, or layering in 2–3 months

dermis

Non-human-derived

Temporary Hyaluronic acid Versatile, for deep and medium injection 6–9 months

Calcium Deep, for rolling scars (off-label) 1 year

hydroxyapatite

Permanent Liquid silicone Rolling scars (not FDA-approved) Many years


constituents. In terms of persistence of action, silicone

is near-permanent; calcium hydroxyapatite has a

longevity of 1–1.5 years, hyaluronic acid derivatives of

6–9 months, and collagens of 2–3 months. Longer-

lasting fillers are injected deeper (Fig. 8.6), at the der-

mal–subcutaneous junction, for correction of deeper

acne scars. Liquid silicone must be injected in very

small aliquots, using the ‘microdroplet’ technique, to

minimize the risk of a delayed immune response.

Unless silicone is being used, patients should be

advised that the correction provided by fillers is tem-

porary.The first time a filler is used, a short-acting one

like collagen or hyaluronic acid should be considered,

because it is important to establish that the cosmetic

effect is appropriate before this is made longstanding

with a more persistent filler.

In general, fillers are more successful for improve-

ment of rolling scars rather than bound-down ice-pick

or boxcar scars. If rolling scars are being treated, sub-

cision may precede use of fillers.The subcised scars are

more mobile and likely to float up after injection of

filler material into their bases.

Not all fillers are prepackaged. Autologous fillers

that can be harvested before injection include blood

and fat. Blood can be removed via blood draw and then

injected deep into atrophic or depressed acne scars.40

Injection can be repeated at monthly intervals, and can

result in raising of the scar both by direct volume

effect and by initiation of a wound-healing cascade

that causes reactive fibrosis. For fine, shallow acne

scars, injection of blood can be performed using a

1ml syringe and 30-gauge needle to raise a bruised

bleb high in the dermis; this can be combined with

postinjection vascular laser treatment at approxi-

mately 50–75% the normal fluence to activate the

hemoglobin chromophore and thus facilitate scar

involution while reducing redness. Laser treatments

may be repeated at monthly intervals.Another autol-

ogous filler is fat.41

Autologous fat can be harvested

from the abdomen or hips and then injected via a

fine cannula into an area of depressed rolling scars.

Excess fat can be frozen for later use, although

defrosted cells are not viable but rather serve as a

biocompatible filler. Fat transfer with fresh fat can

provide some permanent correction, with a fraction

of the implanted cells continuing to thrive at the

recipient site. Current research indicates that use of

adult adipose-derived stem cells can augment the

effect of fat transfer. The degree of fat transfer cor-

rection, and its persistence, is paradoxically inversely

related to the quantity of fat transplanted: filling the

defect area to turgidity can reduce fat survival by

impairing vascular supply to the living cells. Like

blood injection, fat transplantation can be repeated.

Unlike blood transfer, fat transfer is inappropriate

for shallow superficial scars.


ZYDERM IZYDERM II

ZYPLAST

Fig.8.6 The depth of injection of filler agents is contingent on their viscosity and duration of action,with thicker,

longer-lasting materials injected at the dermal–subcutaneous junction (lower arrow),and finer materials like

collagens injected higher.


TREATMENT OF HYPERTROPHIC

ACNE SCARS

Acne scars, particularly of the chest and back, can

become hypertrophic, and rarely keloidal. Management

of such scars is similar to that of hypertrophic scars

caused by other phenomena. Recently, it has become

evident that intralesional injection of cytotoxic agents

may induce remission of selected hypertrophic

scars.42,43

Cytotoxic agents may be an alternative to the treat-

ment of hypertrophic and keloidal scars with high-

strength intralesional corticosteroids.44–47

5-Fu at a

concentration of 50 mg/ml may be combined in an

80:20 ratio with a low-potency intralesional steroid

solution.A typical scar is filled with 0.1–0.3 ml of this

mixture, and a total of about 1 ml used per injection

session. Intralesional verapamil has also been reported

to be of some utility when injected at a concentration

of 2.5 mg/ml, with 0.5–2 ml per scar.48

Topical

imiquimod49

may be an adjunctive prophylactic treat-

ment applied at the surgical site immediately after sur-

gical keloid excision, but treatment efficacy has not

been consistently seen. Radiation therapy can success-

fully shrink keloids; however, in younger patients, and

at head and neck sites, the associated long-term risks

can preempt this approach.

CONCLUSIONS

Treatment of acne scarring, itself a complex problem,

requires a well-organized plan, a willing patient, and a

skilled physician. Usually a range of techniques,

including more or less ablative resurfacing, surgery,

and injection, are required (Figs 8.7 and 8.8). Scarring

cannot be entirely erased, and treatment of scarring in

a field of active acne can exacerbate the latter; for this


Fig.8.7 Lower cheek, chin,and perioral acne scarring

before (a) and after (b) fat transfer, subcision,and laser

resurfacing.

Fig.8.8 Chin and jawline area scarring (a) that is

diminished after skin rolling and subcision (b).

a

b

a

b


reason, the best treatment of acne scarring remains the

prevention of active acne.

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INTRODUCTION

During the natural course of aging, the face undergoes a

series of predictable changes. The skin loses its elastic-

ity through a loss of integrity of both collagen and

elastin fibers in the dermis, resulting in visible static

rhytids and deeper furrows. Furthermore, a loss of adi-

pose tissue, most notably in the midface, leads to volu-

metric depletion of the underlying soft tissue support of

the facial skin. The result of these two changes is a

gravitational descent of the facial tissues that contributes

to hollowing of the cheeks, descent of the malar fat

pads, and deepening of the nasojugal, malar–palpebral,

and nasolabial folds.This can be further compounded by

the effects of exposure to ultraviolet radiation, which is

known to accelerate the aging process by promoting

elastolysis, collagenolysis, and dyschromia.

An increased number of patients are seeking consul-

tation for treatment options in an effort to reverse

many of these visible signs of aging. Our population is

becoming more concerned with its appearance and is

becoming more proactive in seeking out procedures

that will reverse the aging process. Furthermore, the

general trend continues to be for patients seeking less

invasive procedures with less downtime. In the past,

cervicofacial rhytidectomy, deep chemical peels, or

full-face laser resurfacing1,2

were the only options for

achieving significant rejuvenation. These procedures

delivered excellent results; however, these results

came at the cost of significant downtime. Over the past

3–4 years, several new devices have arrived on the mar-

ket providing alternatives to traditional skin tightening

procedures. These newer devices utilize volumetric

heating of the dermis, through either radiofrequency

or near-infrared energy, as a non-ablative method to

tighten the skin.The physiological basis of the effect is

a result of the effects of the heating upon collagen

fibers in the dermis. Collagen fibers are triple-helix

protein chains, which denature and become an amor-

phous, random-coil structure upon heating.3

This

results in shortening of both the length and diameter

of collagen fibrils. Ross et al4

have suggested that after

collagen shortening, fibroblasts in the heated region

begin the synthesis of new collagen fibers, resulting in tis-

sue remodeling at the cellular level, and skin tightening at

the cosmetic level. Currently, there are two significant

noninvasive skin tightening devices available on the

market. Other devices are available and others are

soon to be released; however, none of these has

demonstrated reliable results. The first device, the

ThermaCool TC, utilizes radiofrequency (RF) energy

to heat the dermis and create skin tightening, while the

second device, the Titan, uses near-infrared light to

achieve the same end. These procedures deliver safe

and effective skin tightening with the promise of no

downtime. Although the overall results are variable

and may be only modest, many patients with only early

signs of aging, or those with active lifestyles or busy

careers, will often opt for a lesser procedure in

exchange for less downtime. For those patients who

suffer from extensive skin laxity on deep rhytides or

who desire maximal rejuvenation, rhytidectomy and

laser resurfacing continue to be the gold standards by

which all procedures are compared. Careful patient

selection and counseling and establishing appropriate

expectations become extremely important when

determining the appropriate procedure for the

patient.

9. Nonsurgical tightening

Edgar F Fincher


MONOPOLAR RADIOFREQUENCY

Background

Approved by the US Food and Drug Administration

(FDA) in the spring of 2003 to elevate the brow,

ThermaCool TC (Thermage Inc., Hayward, CA) has

been used in a number of different applications to

reduce skin laxity in the face and upper neck. The

ThermaCool TC is now FDA-approved for treating

rhytids on all areas of the body. It works by delivering

a safe, alternating-current monopolar RF signal in a

nonablative, uniform fashion to tissues. Operating at a

frequency of 6 MHz, the ThermaCool TC generates

heat in the underlying skin tissues by virtue of resis-

tance (impedance).The amount of resistance will vary

depending upon the tissue composition, and studies

have shown that the higher tissue resistance, and thus

the major thermal effect, is in the dermis and subcuta-

neous layers. To prevent injury to the epidermis, a

direct-contact dynamic cryogen cooling system is

incorporated into the handpiece to ensure uniform

constant cooling throughout the treatment period.The

depth of effect of the ThermaCool TC depends on the

geometric size of the treatment tip, while the degree

of the effect depends on the conductive properties of

the tissue. With the standard medium-depth 1.5 and

3.0 cm2

tips, approximately 60–70% of the energy

is delivered to the dermis at a depth of around

2–2.5 mm. The remaining 30% dissipates throughout

the surrounding and deeper tissues, providing signifi-

cant heating at depths of around 4–5 mm. Tissues

possessing a higher impedence, such as fat, tend to

generate a greater degree of heat, resulting in a deep-

tissue thermal effect.5,6

A second factor in understand-

ing the clinical effects of the ThermaCool TC is the

effect on the fibrous septae within the fat compart-

ment. Studies have demonstrated that a large amount

of the RF energy is dissipated or channeled through

the fibrous septae that separate the fat compartments.

This effect leads to heating of these fibrous bands and

their subsequent shrinkage to further contribute to the

overall skin tightening effect. Monopolar RF therefore

provides not only dermal heating and tightening, but

also deep tissue effects that contribute an additive

effect to the global skin contraction.

Treatment Parameters

The use of the ThermaCool TC as a deep-tissue tight-

ening procedure enables patients to experience a safe

and effective treatment for mild to moderate skin

laxities. Its benefits include a quick recovery period

and an excellent safety profile. The major drawback

of the procedure, however, is the discomfort experi-

enced by some patients undergoing treatment.

Thermal energy can lead to sensations of deep heat,

burning, or a sharp stabbing pain.These can often be

minimized with the use of topical anesthetics or oral

analgesics; however, the use of complete sedation or

anesthesia is not recommended as it prevents any

patient feedback, which is an important safety mea-

sure of this device. Recommendations are for physi-

cian operators to adjust energy levels based upon

patient feedback. The maximal treatment parameter

should be set to a point where the patient experi-

ences moderate, but comfortable, heating. Pain, dis-

comfort, or intense heating should not be allowed, as

this lowers the threshold for overheating, burns, or

deep-fat atrophy.

Current protocols involve performing multiple

passes (three to five) at low to moderate fluences

instead of the previously recommended single-pass

high-fluence protocol. Studies have demonstrated that

this multiple-pass lower-fluence protocol provides

equivalent collagen contraction and skin tightening as

the single-pass high-fluence treatment.

The current protocol utilized in our office includes

two complete passes at maximal fluence across the

entire treatment area. Maximal fluence, in this case,

is defined as the highest setting that the patient can

comfortably tolerate. We ask the patient to report

discomfort on a scale of 1–10, where maximal toler-

ability means 6–7. The majority of these pulses will

elicit only minimal discomfort; however, several

areas, such as the malar prominence, the preauricular

region, along the mandible, over the sternocleido-

mastoid, and the supraorbital areas, are reliably the

most painful areas to treat, and a decreased fluence

or only a limited number of passes may be used in

these areas if discomfort is high. Once the two

complete passes have been achieved, an additional

three or four focal passes are performed along key



tightening points. These areas typically include the

skin overlying the lateral malar area and zygoma,

lateral to the nasolabial fold, and along the mandible.

These passes continue until visible tissue tightening is

observed (Fig. 9.1).

Clinical effects

The data compiled from research thus far suggest that

this novel RF device provides a safe and effective tech-

nique to tighten the skin of the face and upper neck 6–13

(Fig. 9.2).The tissue tightening effects of the Therma

Cool TC have also been analyzed in split-face studies,

providing direct comparisons between control and

experimental treatments in the same patients. This

objective, split-face study determined that RF treatment

resulted in remarkable improvements in brow

position, superior palpebral crease, angle of the eye-

brow, and jowl surface area.12

After a single treatment,

patients on average exhibited 4.3 mm of brow eleva-

tion, 1.9 mm of superior palpebral crease elevation

along the midpupillary line, and 2.4 mm of brow

Nonsurgical tightening 105

Fig.9.1 This patient was being assessed midway through

her treatment.She had undergone two complete passes

followed by three focal passes to the left side of the face only.

Signs of immediate skin tightening are evident as softening of

the nasolabial fold, slight elevation of the malar fat pad,and

softening of the jowl.

Fig.9.2 A patient before (a) and 3 months after (b) monopolar radiofrequency (ThermaCool TC) treatment to her entire face.

Although results are often difficult to appreciate using standard two-dimensional photography, careful examination shows

moderate improvement along the nasolabial fold and mandibular line.

a b


elevation along the lateral canthal line. In addition,

the peak angle of the eyebrow became more acute by

an average of 4.5°, and there was a mean decrease of

22.6% in the surface area of the jowls.12

Especially

noteworthy is that these results were achieved without

significant downtime or serious side-effects.

An important issue with this device is that it is well

recognized that there is some variability in the

expected response from patient to patient, with some

patients showing only limited improvement. Several

studies have been published analyzing criteria for deter-

mining which patients are most likely to respond to

treatment. In a group of patients evaluated over a 6-

month period following treatment, it was determined

that there was improvement in submandibular and

upper neck skin laxity in 17 out of 20 patients.

Subjects who did not respond to treatment were found

to be older than 62 years.9

This age-dependent

response was also supported in a study by Hsu and

Kaminer,6

who performed a single RF treatment in the

lower face and neck of 16 patients. It was found that

younger patients responded better to RF treatment,

with the average age of patients not showing satisfac-

tory outcomes from the treatment being 58, compared

with 51 in the group of patients showing clinical

improvement. The ineffectiveness of the procedure on

older patients can theoretically be attributed to the fact

that collagen bonds are replaced by irreducible multi-

valent crosslinks with age. This renders the functional

basis of RF tissue tightening ineffective, as the thermal

injury caused by RF treatment cannot break collagen

bonds held together by multivalent crosslinks.

The deep tissue tightening effects after RF treat-

ment, coupled with the low side-effect profile and

noninvasive techniques, makes the ThermaCool TC a

safe and effective alternative to surgery in patients

with mild to moderate skin laxity. Further studies on

RF treatment still have to be carried out, however, as

the duration of tightening in treated patients has yet to

be determined.

Side-effects and limitations

The ThermaCool TC device has been on the market

for over 3 years at the time of writing. Over that

period of time, it has demonstrated an extremely safe

track record. The evolution of the device has

included multiple safety updates to the equipment,

including the addition of multiple thermal sensors on

the treatment tip in order to constantly monitor and

adjust epidermal temperature, an enhanced dynamic

cooling system to also maintain safe parameters, and

modifications to the recommended treatment ener-

gies and profiles. RF tissue tightening can also result

in temporary side-effects, such as focal erythema,

edema, skin tenderness, mild burns, and rare dyses-

thesia.6–12

Generally, these effects last only a few

hours, but have been reported to persist for several

days to over a week.The complication of treatment

with the ThermaCool TC giving rise to the greatest

concern was the rare occurance of focal fat atrophy.

Early in the course of the history of the ThermaCool

TC, there were several cases of permanent fat atro-

phy that occurred following treatment. Although

these cases were few and restricted to a small num-

ber of users, these permanent alterations created

a great deal of concern about the safety of this device.

Further investigation revealed that these compli-

cations were the effects of excessively high energy

delivered to areas of high fat content. The net effect

of short-pulse high-energy RF energy was necrosis

or melting of the underlying fat, with residual

permanent defects. The treatment protocols were

subsequently modified to ensure that treatments

were conducted well within safe limits. The current

protocols described above include multiple-pass low

to moderate energy levels to achieve the desired

effect.

Other potential side-effects include the risk of scar-

ring or temporary blisters. The actual incidence of

these effects is extremely low when protocols and

treatment techniques are followed. If a blister occurs,

it is generally very superficial and can be successfully

managed by treatment with moist occlusion, with an

anticipated recovery time of around 1 week. The

biggest attraction of this device, unlike many other

technologies available these days, is that it truly meets

the zero-downtime claim. Any sort of side-effect is

extremely rare, and the vast majority of patients will

immediately return to their daily activities without

interruption.



Newer applications and

additional uses

New treatment protocols are being developed for

off-face and eyelid applications with the ThermaCool

TC. A new 0.25 cm2

tip is available for treating the

upper eyelid.This is intended for use in patients with

early blepharochalasis. This ‘eye-tip’ has a different

energy profile than the standard 1.5 or 3.0 cm2

medium-depth tips.The heating profile of the ‘eye-tip’

is more superficial, and it is thus appropriate for the

thin skin of the upper eyelid. Again, a multiple-pass

low-energy treatment protocol is used for the upper

eyelid. Appropriate patients for eyelid treatment are

young patients with early eyelid laxity. Patients with

fat herniation or excessive skin redundancy are better

served by surgical blepharoplasty.

‘Tummy by Thermage’ is the latest treatment proto-

col to be announced by the Thermage Corporation.

Although many users have been performing treat-

ments to the abdomen, arms, and legs for years, this

new protocol is the first to be approved by the com-

pany. This protocol also uses the 3.0 cm2

medium-

depth tips in a multiple-pass low-energy treatment

protocol. Fluences are adjusted based upon patient

comfort levels, and typically range from 352.0 to

354.5. A new variation in treatment technique is what

sets this protocol apart from previous ones. The

abdominal treatments are performed using the tempo-

rary marking grids; however, the pulses are delivered

in a staggered partially overlapped protocol.The oper-

ator alternates between squares and circles to provide

a 25% overlap. This stacking or partial stacking of

pulses prolongs the thermal profile to provide

enhanced skin tightening. The ability to stack or par-

tially overlap pulses also raises the question whether

similar applications on the face or neck can safely pro-

vide greater skin tightening in these areas.

The use of RF energy in combination with tumes-

cent liposuction is another area of potential applica-

tion. Although this treatment combination is not

recommended by the Thermage Corporation due to

an uncertainty in RF energy distribution through

partially undermined or tumesced tissues, many

operators have empirically reported enhanced out-

comes with this combination. In our practice, we

routinely utilize this approach with cervicomental

liposuction and have performed a limited number of

abdominal cases to achieve maximal skin contraction.

It must be stressed that there is no patient feedback

under tumescent anesthesia and that this procedure

should only be performed by experienced operators

with fluence settings that are well within the usual

and safe limits.

NEAR-INFRARED SKIN TIGHTENING

Background

A newer device for noninvasive skin tightening is

the Titan by Cutera (Cutera, Inc., Brisbane, CA).

Currently, the Titan is FDA-approved for dermal heat-

ing and is used in an off-label application for cosmetic

treatments. The Titan produces dermal heating

through the emission of near-infrared light between

1100 and 1800 nm. This near-infrared spectrum of

light has water as the target chromophore, thus in turn

causing heating of the dermal tissue to a depth of

1–2 mm. Similar to RF tissue tightening, the ultimate

effect of dermal heating is thermal modification, lead-

ing to secondary collagen synthesis and remodeling of

skin tissue. The major difference between these two

devices is the thermal profile. As previously men-

tioned, the monopolar Rf device (ThermaCool TC)

focuses the majority of its energy at a depth of approx-

imately 2 mm; however, there is still deeper penetra-

tion of approximately 30% of the energy to depths of

around 4–5 mm. Furthermore, the RF energy dissi-

pates through other structures such as the fibrous sep-

tae that may also contribute to tissue tightening. The

Titan device deposits its energy in a very discrete area

around 1–2 mm, with little deeper diffusion, thus pro-

viding focused tissue heating in the dermis.

The Titan XL handpiece has a large spot size

(1 cm × 3 cm), and can emit pulses of light up to 8.1 s,

making it the only infrared light of its kind. As with

RF tissue tightening devices, contact heating of the

skin would normally cause damage to the epidermis.

As a result, the Titan employs a pre-, parallel, and

post-contact cooling system through a sapphire

window, providing epidermal protection. Contact



cooling is employed in combination with a surface gel.

The use of refrigerated gel is highly recommended to

provide additional cooling, epidermal protection, and

nhanced patient comfort.

Controlled clinical trials that objectively examine the

effects of the Titan are, as yet, unpublished. However,

two papers have provided some preliminary evidence

that are worth mentioning. In the first, Ruiz-Esparza

et al14

reported on a series of 25 patients treated with the

Titan for eyebrow lifting only, eyebrow lifting in addition

to cheek and neck skin laxity, and lower face only.

The shortcomings of this paper were that there was no

objective measurement of clinical changes nor was there

standardization of the treatment parameters. Patients

received a wide range of energy settings, with a large

variation in the number of total pulses, and a few patients

even received multiple treatment sessions. The results

from the series showed that 22 out of 25 patients dis-

played improvement in at least one of the treated areas.

The three patients who did not respond at any treatment

site had no similar differences in age, sex, or skin type.

In addition, the series also compared the effects of low

fluence versus high fluence on the clinical outcome.

Patients were divided into two subgroups: the first

group of patients received low-fluence (20–25 J/cm2)

treatments and less than 150 total pulses. The

second subgroup received higher-fluence treatments

(≥30 J/cm2) and a higher number of total pulses

(150–360). The results demonstrated that although the

lower-fluence subgroup experienced significantly less

discomfort, they showed relatively little or no response

to the treatment. In contrast, groups receiving higher

fluences produced beneficial results.14

Side-effects

reported in this series included three patients who expe-

rienced superficial second-degree burns, which self-

resolved. There were no other reported complications.

A second study, by Zelickson et al,15

reported on the

histological effects of treatment with the Titan device.

These authors evaluated the immediate tissue effects of

the infrared device on cadaveric forehead skin and live

abdominal skin to determine the depth of collagen fibril

denaturation. In the cadaveric forehead skin, treatment

with fluences of 50 J/cm2

and 100 J/cm2

lasting 5–10

seconds resulted in collagen fibril denaturation in the

depth range between 1 and 2 mm. Abdominal skin

treatments (with fluences of 30 J/cm2, 45 J/cm

2, and

65 J/cm2) showed similar results, as the 0–1 mm and

1–2 mm depth ranges showed a significant amount of

collagen fibril denaturation.The 0–1 mm range showed

a lesser severity in collagen denaturation, however, as

the cooling function of the Titan worked to preserve

epidermal integrity. The results from this study show

that thermal injury caused by the Titan induces the

desired immediate tissue effects at an optimal depth

beneath the skin believed to be responsible for produc-

ing the beneficial cosmetic effect achieved from deep-

tissue tightening. A shortcoming of this study was that

there was no long-term follow-up on the actual clinical

effects of the treatment.

Combination Technology

Newer combination technology, such as the ReFirme

(Syneron LTD, Yokneam, Israel), combined bipolar

radiofrequency with broad spectrum light source and

have also shown promising results for skin tightening

in a painless fashion.

Treatment parameters

Similar to monopolar RF, energy settings with the

Titan device are determined based upon patient com-

fort.The maximal energy is considered to be the level

at which the patient experiences mild discomfort.This

can be defined as feeling a moderate heating sensation

for a split second, or as experiencing 6 out of 10 on a

pain scale. It is not recommended that this level be

exceeded, as there is potential for overheating of the

skin, with subsequent blistering. In our practice, the

Titan device has been used to treat the forehead, mid-

face, neck, chest, arms, legs, and abdomen. Energy

levels vary depending upon the treatment site and

patient tolerance. Regardless of the area treated,Titan

treatments consist of multiple nonoverlapping passes

delivering low energy. The total number of passes is

usually around three to five to achieve visible tightening

of the treated area.

Clinical effects

As with other nonsurgical skin tightening devices, the

exact degree of skin tightening will be variable. This



makes the endpoint difficult to predict for both surgeon

and patient. Another important factor to note is the

delay to achieving the final endpoint. In most of our

cases, patients did not achieve maximal correction until

3–5 months post treatment. Even at this point of maxi-

mal correction, many of the changes were difficult to

perceive without examining preoperative photographs.

The most common areas to show improvement with the

infrared tightening were the mandibular line, which

became more defined with a less prominent jowl area.

The second most common area to demonstrate

improvement was an elevation of the malar fat pad and

concomitant softening of the nasolabial fold (Fig. 9.3).

In our hands, this device provided limited improvement

in the neck and brow regions. It is extremely important

to point out these factors and limitations to patients

during preoperative consultation so that realistic expec-

tations can be set appropriately.

Side-effects and limitations

The delivery of infrared light to the skin under appro-

priate guidelines is an extremely safe modality.

Reports of adverse events thus far are limited to a very

small number of superficial scars. The majority of

these have occurred on the upper forehead, and it is

believed that reflected energy from the underlying

cranium was responsible for thermal injury to the

skin. It is important to follow the recommendations

for low-energy multiple-pass treatments with extra

caution over bony prominences such as the forehead,

mandible, and malar prominence. Furthermore,

sufficient contact gel must be used in order to provide

adequate coupling for surface cooling.

Future directions

A question that is yet to be determined is whether serial

treatments provide greater correction than a single

treatment. For example, is it beneficial to perform three

monthly treatments with infrared skin tightening to

enhance the final outcome? Although no published data

currently exist, many of our patients believe that they

receive extra benefit from their multiple treatments. In

theory, one would expect that the amount of collagen

contraction achieved with one treatment session is

certainly not maximal and that further contraction

could be achieved with additional treatments.The ideal

energy settings, number of passes, and the treatment

interval are all variables that are not known or well

understood.The only way to clearly determine this is

through careful morphometric analysis in a split-face

study and through continued close monitoring and

collection of data from patient treatments.

SUMMARY

We have discussed two noninvasive devices on the

market that are appropriate for treating early skin

laxity. Both of these devices provide zero-downtime

treatments, and therein lies their true strength. No

other treatments available can provide zero downtime


Fig.9.3 A patient before (a) and 3 months after (b) a single full-face treatment with near-infrared (Titan) skin tightening.

Typical results include moderate tightening along the mandibular line,along with attenuation of the jowls and nasolabial folds.

a b


with the potential for some degree of correction.

Although the amount of correction is variable and, at

times, limited, many patients cannot afford or are

unwilling to spend 2–3 weeks recovering from a surgical

procedure.These two devices, therefore, offer alterna-

tives to traditional lifting procedures when patients

can not afford the downtime and are willing to accept

a lesser degree of lifting.

The area of noninvasive skin tightening is still rela-

tively new, and we, as operators, are still learning how

to maximize our results. Certainly, the future will

bring us further technological advancements and other

new devices that will enhance our ability to perform

less-invasive and noninvasive rejuvenation.

REFERENCES

1. Alster TS, Garg S. Treatment of facial rhytides with a

high-energy pulsed carbon dioxide laser. Plast Reconstr

Surg 1996;98:791–4.

2. Khatri KA, Ross EV, Grevelink JM, et al. Comparison of

erbium:YAG and carbon dioxide lasers in resurfacing of

facial rhytides.Arch Dermatol 1999;135:391–7.

3. Lennox G. Shrinkage of collagen. Biochim Biophys Acta

1949;3:170–87.

4. Ross EV, Naseef GS, McKinlay JR, et al. Comparison of

carbon dioxide laser, erbium:YAG laser, dermabrasion,

and dermatome: a study of thermal damage, wound

contraction, and wound healing in a live pig model:

implications for skin resurfacing. J Am Acad Dermatol

2000;42:92–105.

5. Tunnel JW, Pham L, Stern RA, et al. Mathematical

model of nonablative RF heating of skin. Lasers Surg

Med 2002;14(Suppl):318.

6. Hsu TS, Kaminer MS. The use of nonablative radiofre-

quency technology to tighten the lower face and neck.


7. Fitzpatrick R, Geronemus R, Goldberg D, et al.

Multicenter study of noninvasive radiofrequency for peri-

orbital tissue tightening. Lasers Surg Med 2003;33:

232–42.

8. Ruiz-Esparza J, Gomez JB. The medical face life: a non-

invasive, nonsurgical approach to tissue tightening in the

facial skin using nonablative radiofrequency. Dermatol

Surg 2003;29:325–32.

9. Alster TS, Tanzi E. Improvement of neck and cheek

laxity with a non-ablative radiofrequency device: a lifting

experience. Dermatol Surg 2004;30:503–7.

10. Fisher GH, Jacobson LG, Bernstein LJ, et al. Nonablative

radiofrequency treatment of facial laxity. Dermatol Surg

2005;31:1237–41.

11. Koch RJ. Radiofrequency nonablative tissue tightening.

Facial Plast Surg Clin North Am 2004;12:339–46.

12. Nahm WK, Su TT, Rotunda AM, et al. Objective changes

in brow position, superior palpebral crease, peak angle of

the eyebrow, and jowl surface area after volumetric

radiofrequency treatments to half of the face. Dermatol

Surg 2004;30:922–8.

13. Kilmer SL. A new nonablative radiofrequency device:

preliminary results. In: Arndt KA, Dover JS, eds.

Controversies and Conversations in Cutaneous Laser

Surgery. Chicago: American Medical Association Press,

2002:93–4.

14. Ruiz-Esparza J, Shine R, Spooner GJR. Immediate skin

contraction induced by near painless, low fluence irradia-

tion by a new infrared device: a report of 25 patients.


15. Zelickson B, Ross V, Kist D, et al. Ultrastructural effects

of Titan infrared handpiece on forehead and abdominal

skin. Dermatol Surg 2006;327:897–901.



INTRODUCTION

Cumulative exposure to the sun can induce clinical and

histological changes in the skin, commonly called photo-

aging or dermatoheliosis. This occurs primarily in

patients with fair skin types (Fitzpatrick 1 to Fitzpatrick

3 skin types) who have experienced repeated solar

injuries over the years, such as lifeguards and outdoor

laborers.1Clinically, photoaging represents a polymorphic

response to sun damage that manifests variably as wrin-

kles, skin roughness and xerosis, irregular mottled pig-

mentation, telangiectasias (poikiloderma of Civatte),

actinic purpura, sallowness (also known as Milian

citrine skin), and brown macules or solar lentigines.

Besides fair skin, other risk factors for the development

of photoaging include difficulty in tanning, ease of sun-

burning, a history of sunburn before the age of 20,

advancing age, smoking, male gender, and living in areas

with high ultraviolet (uv) radiation (high altitudes).2

Individuals who develop photoaging often have a

genetic susceptibility to photodamage and can experi-

ence sufficient actinic damage to develop skin cancers

such as basal cell cancer or melanoma.

The areas primarily affected by photoaging include

the face, the V area of the neck and chest, the back and

sides of the neck, the backs of the hands and extensor

arms, and, in women, the skin between the knees and

ankles. Photodamaged skin typically appears attenu-

ated, atrophic, scaly, wrinkled, leathery, and, in some

cases, furrowed and ‘cigarette paper-like’. In persons

of Celtic ancestry, photoaging can produce profound

epidermal atrophy without wrinkling, making the skin

appear almost translucent and making dermal struc-

tures such as blood vessels more visible.

Because of its predilection for visible parts of the

body, photoaging-induced pigmentation can have sig-

nificant psychosocial impact on affected individuals.

Unfortunately, treatment of such pigment alterations

has been difficult. Each year, millions of dollars are

spent by consumers seeking ‘quick-fix’ solutions for

the cutaneous stigmata of aging. In 2002, more than 5

million nonsurgical and 1.5 million surgical cosmetic

procedures costing more than $13 billion were per-

formed in the USA.3

We can only expect such num-

bers to increase in the coming decades as our aging

population expands, given increases in life expectancy

and growing consumer demand for improvements in

cosmetic appearance.

While photoprotection with either chemical or

physical sunscreens remains the mainstay of care for

patients with photoaging-induced pigmentation, addi-

tional topical treatments in the form of retinoids,

steroids, chemical bleaches such as hydroquinone,

hydroxy acids, and chemical peels are also available.

Unfortunately, many of these topical treatments are

only able to affect changes at the level of the epider-

mis, while most textural and tinctorial changes in sun-

damaged skin are caused by alterations in structures in

the upper and deep dermis.

The introduction of laser and visible-light technol-

ogy over the past 30 years has revolutionized our

understanding and treatment of photoinduced pig-

mentation by more selectively targeting pigmented

molecules and structures in the dermis without dam-

aging the overlying epidermis. They have also proven

useful in more directed treatment of epidermal pig-

mentation. In this chapter, we will review some of

the more common pigmented lesions associated with

10. Laser treatment of pigmentation

associated with photoaging

David H. Ciocon and Cameron K Rokhsar


photoaging as well as the most current and effective

laser modalities available for their treatment.

SOLAR LENTIGINES

Solar lentigines are the most common of pigmented

lesions induced by photoaging.4

They are macular,

hyperpigmented lesions ranging in size from a few mil-

limeters to more than a centimeter in diameter.They

tend to be multiple and grouped and bear a predilection

for sun-exposed surfaces, including the face, neck,

hands, and forearms.Alternative names for solar lentig-

ines include actinic lentigines, liver spots, age spots, and

sunspots. As with photoaging, the incidence of solar

lentigines increases with time, affecting more than 90%

of Caucasians older than 50 years.When evaluating indi-

viduals with suspected solar lentigines, clinicians must

take care in distinguishing them from ephelides, lentigo

simplex, pigmented actinic keratoses, flat seborrheic

keratoses, melanocytic nevi, and malignant melanoma.

While they can be usually differentiated on the basis of

history and clinical appearance, some cases may warrant

a biopsy.

Although numerous non-laser therapies have been

shown to be effective for solar lentigines, including

retinoic acid, mequinol, and cryotherapy, many of them

require repeat applications over extended periods of

time to achieve significant cosmetic improvement. In

addition, lightening with topical treatment is usually

temporary and incomplete, with the lesions recurring

immediately following cessation of therapy.The primary

advantage of laser treatment of solar lentigines is that

most can be removed completely in one to three treat-

ments, depending on the modality, which provides

patients with more immediate satisfaction.

The primary target in a solar lentigo is the pigment

melanin. Because of the broad absorption spectrum of

melanin, which ranges from 351 to 1064 nm, various

lasers have been used to treat solar lentigines, most

with excellent results. Lasers used in published

reports include the pulsed dye (585–595 nm), copper

vapor (511 nm), krypton (520–530 nm), frequency-

doubled Q-switched neodymium : yttrium aluminum

garnet (Nd:YAG) (532 nm), Q-switched ruby

(694 nm), Q-switched alexandrite (755 nm), Q-

switched Nd:YAG (1064 nm), carbon dioxide (CO2)

(10 600 nm), and argon (488–630 nm) lasers.4

For the

purpose of this review, we will concentrate on three

laser modalities widely regarded as the safest and most

effective for the treatment of solar lentigines: the Q-

switched ruby laser, the Q-switched alexandrite laser,

and the Q-switched Nd:YAG laser.

The Q-switched ruby laser (QSRL) was developed

to emit light in very short pulses that is preferentially

absorbed by melanin, thereby reducing damage to

other skin structures. Q-switched lasers can induce

both photothermal and photomechanical reactions.

These lasers generate high-energy radiation that leads

to a rapid rise in temperature (1000°C), resulting in

evaporation of targeted pigments within the skin and

vacuolization (photothermal damage). The collapse

of the temperature gradient that is created between

the target tissue and the surrounding tissue also

causes fragmentation of the target (photomechanical

damage).

The use of the QSRL for the treatment of solar

lentigines was described in a study of eight women

with 196 solar lentigines on their forearms.5Therapy

was delivered as a single brief pulse of 40 ns to a 4 mm2

area.A single course of treatment resulted in fading of

the lesions without scarring and no recurrence within

a 6- to 8-week follow-up period. Histopathological

examination of biopsy specimens showed vacuo-

lization of superficial pigmentation to a maximum

depth of 0.6 mm immediately after treatment. Immuno-

histochemical examination of specimens stained with

anti-melanocyte-specific antibodies did not indicate

remaining melanocytic structures in moderately

pigmented lesions.

Another Q-switched laser that has been also shown

to be effective for lentigines is the Q-switched

Nd:YAG (QSNd:YAG) laser at 532 nm.A three-center

trial evaluated the effectiveness of the frequency-

doubled QSNd:YAG laser (532 nm, 2.0 mm spot size,

10 ns) in removing benign epidermal pigmented

lesions with a single treatment. Forty-nine patients

were treated for 37 lentigines.6Treatment areas were

divided into four quadrants, irradiated with fluences of

2, 3, 4, or 5 J/cm2

and evaluated at 1- and 3-month

intervals following treatment. For lentigines, response

was dose-dependent, with greater than 75% pigment

removal achieved in 60% of those lesions treated

at higher energy fluences. Although mild, transient

erythema, hypopigmentation, and hyperpigmentation

were noted in several patients, they all resolved



spontaneously within 3 months. No other textural

changes or scarring were noted.

In a subsequent study the safety and efficacy of

the QSRL at 694 nm and the frequency-doubled

QSNd:YAG (1064 and 532 nm) lasers were compared.7

Twenty patients with pigmented lesions (including

lentigines, café-au-lait macules, nevus of Ota, nevus

spilus, Becker’s nevus, postinflammatory hyperpig-

mentation, and melasma) were treated with the QSRL

and the frequency-doubled QSNd:YAG lasers. Clinical

lightening of the lesion was assessed 1 month after a

single treatment. A minimum of 30% lightening was

achieved in all patients after only one treatment with

either the QSRL or the frequency-doubled QSNd:YAG

laser. The QSRL seems to provide a slightly better

treatment response than the QSNd:YAG laser.

Furthermore, most patients found the QSRL to be

more painful during treatment, but the QSNd:YAG

laser caused more postoperative discomfort. Neither

laser caused scarring or textural change of the skin.

At present the QSNd:YAG laser at 532 nm is favored

by many clinicians for the treatment of lentigines in

light-skinned individuals, while the QSNd:YAG at

1064 nm is favored for individuals with darker skin

types.8

One study has recently reported the use of

the Nd:YAG laser in medium skin types such as Asian

skin. Chan et al9

compared the clinical efficacy and

the adverse event profile of three different lasers: the

Versapulse Q-switched (VQS) Nd:YAG at 532 nm, the

Versapulse long-pulse (VLP) Nd:YAG laser at 532 nm,

and a conventional QSNd:YAG laser at 532 nm

(Medlite, Continuum Biomedical, Livermore, CA).

The VLP, unlike the VQS laser, causes tissue destruc-

tion purely through photothermal effects.Thirty-four

Chinese patients with 68 solar lentigines on the face

were treated with one of the three lasers. For the VLP

laser, the spot diameter was 2 mm, with a pulse dura-

tion of 2 ms and fluence of 9–12 J/cm2. For the VQS

laser, the spot size was 3–4 mm with a fluence of

1.0–1.5 J/cm2. The Medlite laser system involved a

spot size of 2 mm, with a fluence of 0.9–1.0 J/cm2.

The mean scores (maximum 10) for the degree of

clearing achieved using both patients’ and clinicians’

assessments were 4.751, 4.503, and 4.78 for the

Medlite,VQS, and VLP lasers, respectively, indicating

no difference in efficacy.

Our treatment of choice is the use of the Q-switched

alexandrite laser (755 nm), as it removes pigmentation

effectively without the purpura commonly associated

with the use of the QSNd:YAG at 532 nm (Fig. 10.1).

With the alexandrite crystal, the laser wavelength is

755 nm, which is longer than that of the ruby laser

(694 nm) and the QSNd:YAG laser at 532 nm. Longer

wavelengths penetrate more deeply into the dermis

and are absorbed less readily by epidermal melanin. If

the skin is irradiated with wavelengths in the

400–600 nm range, oxyhemoglobin will compete

strongly with melanin for absorption of photons, and

vascular damage will occur, resulting in purpura.With

longer wavelengths (> 600 nm), where absorption by

oxyhemoglobin is substantially reduced or absent and

absorption by melanin over blood pigments dominates,

damage is restricted to the melanin pigment-laden

structures (Fig. 10.2). In a study by Jang et al,10

Laser treatment of pigmentation associated with photoaging 113

Fig.10.1 Removal of solar lentigines on the face of a patient with type IV skin after treatment with one session of the

Q-Switched Alexandrite laser (Candela Corporation).

a b


197 patients with freckles were treated with the

Q-switched alexandrite laser at 8-week intervals and

clinically analyzed. The Q-switched alexandrite laser

was operated at 755 nm, with a pulse width of 100 ns

using a 3 mm spot.After a single treatment, all the irra-

diated freckles in 64% of patients were graded as excel-

lent. More than 76% removal of freckles required an

average of 1.5 treatment sessions with 7.0 J/cm2. No

scarring, long-standing pigment changes, or textural

changes were seen.

The superiority of laser therapy over cryotherapy in

the treatment of solar lentigines has been well

described. Todd et al11

have reported a comparative

study of the frequency-doubled QSNd:YAG laser

(532 nm), the HGM K1 krypton laser (521 nm) (HGM

Medical Systems Inc., Salt Lake City, UT), the DioLite

532 nm diode-pumped vanadate laser (Index Corp.,

Mountain View, CA), and cryotherapy. A total of 27

patients with a minimum of six lesions on the backs of

their hands were enrolled in the study. Each hand was

divided into four sectors, and one treatment was

applied per sector.Treatment with the frequency-dou-

bled QSNd:YAG laser involved treatment for 30 ns to

a 3 mm spot; comparative treatments with the HGM

K1 krypton laser and the DioLite 532 nm diode-

pumped vanadate laser were 0.2 s on/0.2 s off to a

1mm spot and 39 ms to a 1 mm spot, respectively.

At 6 weeks after treatment, the frequency-doubled

QSNd:YAG laser was found to provide superior

lightening compared with other treatments. This

level of response was still maintained at 12-week

follow-up. From the patients’ perspective, a survey

showed that they considered this form of laser ther-

apy to produce the best results (n = 18), followed by

diode-pumped vanadate laser (n = 6), cryotherapy

(n = 2), and the krypton laser (n = 1). The fewest

adverse events were reported from use of the Q-

switched laser, whereas the krypton laser had the

highest number of such events. Mild transient ery-

thema was reported for all therapies, with hypopig-

mentation and/or hyperpigmentation and scarring

occurring infrequently.

Intense pulsed light systems (IPLs) have been also

shown to be effective for the treatment of solar lentig-

ines – although less so compared with Q-switched

lasers.8

IPLs emit broadband light containing multiple

wavelengths. Using various filters to include or exclude

particular wavelengths, one can target various struc-

tures in the skin, depending on the wavelength emit-

ted. Like Q-switched lasers, IPLs are also based on the

principle of selective photothermolysis. However, IPLs

are typically less predictable than Q-switched lasers,

due to the wider range of wavelengths being used.

Most often, the removal of lentigines by the IPL is

incomplete and is an added benefit that occurs during

IPL facial photorejuvenation to correct mild wrinkles,

poor skin texture, and telangiectasias associated with

chronic sunlight exposure. Because light from the IPL

must pass through the epidermis in order to reach the

dermal fibroblasts in photorejuvenation, focal melanin

deposits that cause lentigines are inadvertently treated

as well. Once photothermolyzed, these lesions usually

turn a dark brown color and then peel off in 7–10 days.

Because the wrinkle-improvement aspect of IPL gener-

ally takes 6–8 weeks to be seen, and is mild at best,

much of the early patient enthusiasm for IPL stems

from the eradication of solar lentigines and improve-

ment of telangiectasias (Fig. 10.3).

For those individuals seeking to improve pigmenta-

tion as well as fine, moderate, and deep rhytides on

the face, ablative resurfacing with the CO2

laser

(10 600 nm) or Er-YAG laser (2940 nm) remains the

gold standard (Fig. 10.4). The chromophore for both

lasers is water.The CO2

and erbium lasers operate by


Fig.10.2 5 days post treatment of lentigines on hands

with the Q-Switched Alexandrite laser (Candela

Corporation).Typically, crusting is seen,without purpura.

The crusted areas typically peel off within 7–10 days.


vaporizing epidermal and dermal tissue.The depth of

vaporization depends on the device and number of

passes, but in general, in the most aggressive ablative

resurfacing procedures, one does not ablate more than

400 µm of skin. One can reverse the pigmentation

associated with photoaging rather effectively with

ablative resurfacing, with outstanding results not only

in pigmentation and lentigines, but also in deep lines

and furrows. One also sees a degree of tissue tighten-

ing unparalleled with other laser devices. The down-

side is the potential risk for scarring and pigmentary

alteration, which in the worse-case scenario can be


Fig.10.3 Improvement in

telangiectasias and

pigmentation associated with

photodamage following three

treatment sessions with an

intense pulse light (IPL)

source: (a) before; (b) after

treatment. (Photographs

courtesy of Elizabeth

Rostan, MD.)

Fig.10.4 Significant

reduction in pigmentation

and rhytids associated with

chronic photodamage after

a three-pass resurfacing

procedure with the

Ultrapulse CO2

laser.

a b

a b


permanent as the raw skin heals. It is important to

note that the erbium laser can also be used superfi-

cially, with little downtime or erythema. However,

these so called ‘microlaser peels’ have very little effect

on pigmentation.

The newest technology for the improvement of

solar lentigines is fractional resurfacing with the Fraxel

laser (Reliant Technologies, Mountain View, CA).This

is a new concept in laser resurfacing whereby the skin

is resurfaced fractionally (15–30%) in one session.12,13

This is accomplished by the placement of an array of

numerous microscopic zones of thermal damage in the

epidermis and dermis, surrounded by islands of nor-

mal tissue. The normal skin left untreated serves as a

reservoir for healing, allowing the skin to heal rapidly.

This procedure is typically repeated four to six ses-

sions every 2–4 weeks. In this way, one can resurface a

large portion of the skin over time.

Unlike CO2

or erbium laser resurfacing, the skin

is not vaporized during fractional resurfacing, and

therefore there are no full-thickness wounds. Rather,

the skin is photocoagulated. These photocoagulated

zones of thermal damage range from 80 to 150 µm in

diameter and from 300 to 900 µm in depth, depending

on the parameters utilized (Fig. 10.5).The percentage

of the skin resurfaced at one time depends on the com-

bination of energy and final densities used. In four to

six treatment sessions, one can resurface 59–84% of

the skin at a setting that resurfaces 20% of the skin

at a time, and 76–88% at a setting that resurfaces 30%

at a time. The photocoagulated epidermis, which is

referred to as MEND (microscopic epidermal necrotic

debris), is extruded 3–5 days after the procedure; this

is clinically manifested as first bronzing of the skin and

later as fine flaking. The columns of photocoagulated

collagen in the dermis serve as a stimulus for produc-

tion of new collagen. One can thus achieve both epi-

dermal and dermal remodeling over time (Fig. 10.6).

The advantages to this fractional approach to resur-

facing are numerous, from both a theoretical and a

practical perspective. First and foremost, patients

do not have open wounds, minimizing downtime.

Second, anatomical areas that would generally be

highly prone to complications of scarring with tradi-

tional resurfacing lasers, such as the neck, chest, and

hands, can be safely and aggressively treated. Third,

potential complications associated with open wounds,

such as infection and hyper/hypopigmentation and

scarring, are minimized. Fourth, one can potentially

treat deeper dermal pathology. Fifth, water is the chro-

mophore, so tissue interaction, both in the epidermis

and in the dermis, is relatively uniform.Traditionally,

with combined CO2/erbium laser resurfacing, one

ablates tissue approximately 200–400 µm during mul-

tiple-pass procedures. Any deeper treatment risks the

complication of scarring.With Fraxel laser treatment,

one can penetrate tissue much deeper safely, as entire

epidermal and dermal ablation is not achieved. The

diameter of each column of coagulated tissue is small

enough to be invisible to the unaided eye and is sur-

rounded by untreated skin, which provides a tremen-

dous reservoir for healing. Because of these two factors,

tissue can be coagulated within this small column as

deep as 900 µm safely. With the second-generation

Fraxel laser (Fraxel SR 1500) employing a variable

spot size, penetration as deep as 1.1 mm is possible.

The coagulated epidermis is replaced within 24 hours

by an influx of cells from the periphery of the treated

spot, or column.


100 µm

Microscopic epidermal necrotic debris (MEND)

Controlled zones of denatured collagen in the dermis

Fig.10.5 Histological evaluation after fractional

resurfacing with the Fraxel laser.The coagulated epidermis is

referred to as MEND (microscopic epidermal necrotic debris).

The MEND are extruded within a week after the procedure. It

is thought that the improvement in pigmentation is related to

the extruded MEND having a high melanin content.Below

each MEND is a denatured column of collagen (bluish in

color).These columns serve as a new stimulus for collagen

production.


The current Fraxel laser is a fiberoptic laser utilizing a

wavelength of 1550 nm.The laser handpiece is equipped

with a so-called intelligent optical tracking device that is

able to calculate the speed of the operator’s hand against a

background blue dye, adjusting for inconsistencies in

hand speed, to place the intended number of microthermal zone

in a given area. Other manufacturers have also fractionated

the beams of their devices. Palomar manufactures a

device that has a fractionated head allowing for delivery of

fractionated laser spots in a stamping mode. A few laser

manufacturers are in the process of fractionating CO2

or

erbium laser beams in hope of decreasing the patient

downtime associated with ablative resurfacing while

maintaining its superior results.

The Fraxel laser is currently FDA-approved for

treatment of periorbital wrinkles, acne and surgical

scars, skin resurfacing procedures, and dermatological

procedures requiring the coagulation of soft tissue, as

well as photocoagulation of pigmented lesions such as

lentigines and melasma. Solar lentigines on the face,

and indeed anywhere on the body, can be treated.

Multiple sessions are required. It is important to note

that the mechanism of clearance is through nonspecific

resurfacing and is not pigment-specific.Therefore, Q-

switched lasers remain the gold standard for treatment

of distinct lentigines. Fractional resurfacing is useful in

those individuals who seek improvement of diffuse

pigmentation or additionally seek improvement in

texture, wrinkles, and (acne) scars.

DERMATOHELIOSIS

Long-term sun exposure results in wrinkled, inelastic

skin that reflects a loss of collagen in the mid to upper

dermis, with concomitant accumulation of elastotic

material.14,15

This process is referred to as solar elasto-

sis, reflecting these histological changes.The elastotic

material is derived largely from elastic fibers, stains

with histochemical stains for elastin, and demonstrates

marked increased deposition of the protein fibulin 2

and its breakdown products. The mechanism behind

collagen loss in photodamaged skin may be the upreg-

ulation of matrix-degrading metalloproteinases such

as collagenase and gelatinases following UV irradiation

of the skin. In addition, UV radiation causes significant

loss of procollagen synthesis in the skin.16

Patients with dermatoheliosis present with an over-

all sallow, wrinkled complexion. Unfortunately, few

topical regimens are effective in treating this condi-

tion because the pathology lies in the mid to upper

dermis. Fortunately, various light-based technologies

are available to help improve the appearance of

patients with this common condition.


Fig.10.6 Improvement in pigmentation,actinic keratosis and rhytides after fractional resurfacing with four session of the

Fraxel laser: (a) before; (b) after treatment.

a b


The gold standard for treatment of solar elastosis

on the face remains ablative resurfacing with CO2

or erbium lasers. Tissue is vaporized from 200 to

400 µm. As the raw skin heals, a wound healing cas-

cade is initiated in which inflammatory cells recruit

dermal fibroblasts to produce new dermal collagen.

This process results in an improvement of wrinkles

associated with photoaging (Fig. 10.7). Both deep

lines and pigmentation associated with photoaging can

be drastically improved with this procedure. The

potential risks are infection, scarring, and hyper/

hypopigmentation, which can at times be delayed.

As mentioned above, fractional resurfacing with the

Fraxel laser has been promising in the treatment of

fine wrinkles, texture and dermatoheliosis. Fractional

resurfacing treats photodamaged skin by targeting only

a small fraction of the skin surface in each treatment

session. Photodamage to the face (Fig. 10.8), neck,


Fig.10.7 Significant reduction in wrinkles associated with chronic sun damage after a multipass resurfacing procedure with

the Ultrapulse CO2

laser: (a) before treatment; (b) at 6 months’ follow-up.

Fig. 10.8 Reduction in pigmentation and fine lines after resurfacing with five sessions with the Fraxel laser: (a) before; (b) aftertreatment. (Photographs courtesy of Elizabeth Rostan, MD.)

a b

a b


chest, arms (Fig. 10.9), and hands has been treated

successfully, as have acne scars, other scars, and

various types of dyschromia, including melasma. This

treatment regimen has produced more significant

improvements in texture, color, and deep lines than are

commonly seen with other nonablative technology. In

a study conducted by Rokhsar and Fitzpatrick,13

an

improvement of 1.5 was seen in the wrinkle score

following four to six sessions with the Fraxel laser,

utilizing the Fitzpatrick wrinkle score, measuring

wrinkles on a scale of 1–9.

Dermal remodeling with IPL has been a source of

renewed interest. In a study by Goldberg,17

five patients

underwent four sessions of dermal remodeling with an

intense pulsed light source. All patients received a pre-

treatment biopsy and a second biopsy 6 months after the

initial treatment. Biopsies were evaluated for histological

evidence of new collagen formation 6 months after the

initial treatment.While pretreatment biopsies showed

evidence of solar elastosis, the post-treatment biopsies

showed some degree of superficial papillary dermal

fibrosis, with evidence of an increased number of fibro-

blasts in scattered areas of the dermis. Such changes, the

author concluded, were evidence of new dermal colla-

gen formation. Recently, investigators have reported

better results by combining IPL with δ-aminolevulinic

acid (ALA). However, it still appears that improvement

in fine lines is subtle at best with IPL treatments.

Various other lasers have been shown to induce

nonablative dermal collagen remodeling, including

the 1320 nm Nd:YAG laser, the 1450 nm diode laser,

and the 1540 nm Er:glass device. However, in reality,

the results are often not reproducible – or are subtle

at best. Because of their longer wavelengths, these

lasers are more deeply penetrating and less damag-

ing to the epidermis, while being minimally

absorbed by melanin. They use water as a chro-

mophore and are intended to target dermal colla-

gen. It is generally accepted that this class of lasers is

the least effective in treatment of wrinkles associated

with photoaging.

POIKILODERMA OF CIVATTE

Poikiloderma of Civatte refers to erythema associ-

ated with a reticulate pigmentation and telangiec-

tasias usually seen on the sides of the neck, lower

anterior neck, and the ‘V’ of the chest. Civatte first

described the condition in 1923. It is a rather

common, benign condition affecting the skin. Many

consider it to be a reaction pattern of the skin to

cumulative photodamage, since the submental area,

shaded by the chin, is typically spared. It frequently

presents in fair-skinned men and women in their mid

to late 30s or early 40s.


Fig.10.9 Improvement in

pigmentation and textural

abnormalities associated

with sun damage after

combination treatment with

the Q-switched alexandrite

laser (one session) and the

Fraxel laser (four sessions):

(a) before; (b) after treatment.

(Photographs courtesy of

Richard Fitzpatrick MD.)

a b


The blue–green argon laser was the first laser system

used for treating poikiloderma of Civatte. Although it

offered improvement, this treatment had significant

side-effects, most notably scarring.The 532 nm potas-

sium titanyl phosphate (KTP) laser introduced later was

an improvement, although complicated by cases result-

ing in occasional hypopigmentation.

Treatment options for poikiloderma of Civatte were

revolutionized with the advent of the pulse dye laser

(PDL).18

PDLs were first introduced in 1989, with the

first laser emitting light at 577 nm, coinciding with the

last peak of the oxyhemoglobin absorption spectrum

(418, 542, and 577 nm). Because its target chro-

mophore was hemoglobin, the PDL quickly became the

treatment of choice for vascular lesions, including

telangiectasias, hemangiomas, and portwine stains. By

lengthening the wavelength to 585 nm, the PDL

achieved deeper penetration into the dermis without

compromising vascular selectivity. Currently available

PDLs emit a wavelength of 585 or 595 nm with longer

pulse durations.Although there is deeper penetration of

energy at 595 nm compared with 585 nm, the absorp-

tion of oxyhemoglobin is less after 585 nm.Therefore to

compensate for this decreased absorption, the 595 nm

PDL requires an additional 20–50% of fluence

compared with 585 nm systems.

Because telangiectasias are a prominent feature of

poikiloderma of Civatte, the PDL provides a superior

treatment alternative for this condition. In one study,

seven female patients (ages 42–52 years) with clini-

cally typical poikiloderma of Civatte, which they

considered to be causing significant cosmetic disfig-

urement, were treated with a PDL at a wavelength of

585 nm and a pulse duration of 0.45 ms (SPTL-1B;

Candela Corp., Wayland, MA).19

All seven patients

were of skin type I or II (i.e., they burnt easily, with

little or no tendency to tan), and in all of them reticu-

late telangiectasia was the most prominent compo-

nent of the condition. In all of the patients, a test

patch was treated and reviewed at 3 months.

Subsequent treatments were undertaken at intervals

of 3 months.The fluences used were 5.0 J/cm2

with a

10 mm beam diameter (five patients) and 7.0 J/cm2

with a 7.0 mm beam diameter (two patients).Topical

anesthesia with EMLA cream or cooling with ice was

used. Results were assessed by one of the two authors

and graded as excellent (vascular component of the

lesion not visible), good (partial clearing of 50% of

the vascular component of the lesion), or poor (no

visible change).

Five patients had an excellent result, one had a good

result, and one had a good result with respect to

clearing of the vascular component but an overall

unsatisfactory cosmetic result due to scarring and

hypopigmentation in the treated area. This adverse

result is of some interest, since the test patch did not

produce any scarring or pigment change, and the

changes did not occur until 4 months after the treat-

ment. This patient had been treated at a fluence of

7.0 J/cm2. No other adverse effects were noted – in

particular, no pigment changes.

Subsequent studies have attempted to delineate fur-

ther the adverse outcomes associated with PDL treat-

ment of poikiloderma of Civatte, particularly since

uniform guidelines for treatment of the condition do

not exist. In a study by Meijs et al20

eight patients

(seven women and one man, mean age 48 years) with

poikiloderma of Civatte were treated with a PDL

using a 585 nm wavelength and a fixed pulse duration

of 0.45 µs. In all patients, one or two test PDL patches

were performed and reviewed after 3 months. All of

the patients tolerated the testing without complica-

tions. Subsequent treatments were undertaken at

intervals of 3 months. All patients were treated with

fluences between 3.5 and 7 J/cm2, using a 7 or 10 mm

spot size.All had a good result with respect to clearing

of the vascular component. Nevertheless, six of them,

treated with 5–7 J/cm2, reported severe depigmenta-

tion 4–11 months after treatment. Two patients

treated with lower fluences (3.5–5.5 J/cm2), how-

ever, did not report this depigmentation.Therefore, to

avoid depigmentation, the authors recommend using

fluences as low as possible when treating dark-skinned

individuals for poikiloderma of Civatte with PDL and

not exceeding an upper limit of 5 J/cm2, on a 10 mm

spot size.

Incomplete clearing of poikiloderma of Civatte is

typically a result of poor light penetration depths in

blood. For example, the light penetration depths in

blood at 532 and 585 nm wavelengths are approxi-

mately 37 (absorption coefficient approximately

266 cm−1

) and 52 µm (absorption coefficient approx-

imately 191 cm−1

), while the ectatic blood vessels of

poikiloderma of Civatte are approximately 100 µm



in diameter. As a result, large blood vessels cannot be

completely coagulated, resulting in incomplete clear-

ing of poikiloderma of Civatte, even with the PDL. A

new high-energy PDL (V-Beam; Candela), capable of

producing higher fluences with larger spot size, is

equipped with a glass slide that is used to physically

displace blood in the skin, allowing the energy to be

preferentially absorbed by melanin. Although new,

this laser holds greater promise in the treatment of

pigmentation and telangiectasias associated with

poikiloderma.

IPL has also been widely used for the treatment of

poikiloderma.21, 22

As IPL covers a broad range of wave-

lengths, it can potentially treat both the vascular and

pigmented components of poikiloderma. Usually, three

to five sessions are necessary to achieve optimal results.

A potential negative outcome that can be associated

with the use of IPL in the treatment of poikiloderma is

the pin-striping developed by some patients and associ-

ated with the use of the rectangular handpieces of IPL

devices. Care must be taken to use the IPL handpiece in

a vertical manner in one session alternating with a hor-

izontal manner in the next to minimize the potential

for pin-striping.

Given that one cannot use ablative resurfacing to

reverse signs of photoaging in body areas commonly

affected by poikiloderma, such as the chest and neck,

due to the risk of scarring, fractional resurfacing has

revolutionized the treatment of poikiloderma (Fig.

10.10). Unlike the modalities based on selective pho-

tothermolysis, which aim to achieve homogeneous

thermal injury in a particular target within the skin,

fractional photothermolysis produces an array of

microscopic regions of thermal injury surrounded by

uninjured dermal tissue. Recent clinical studies indi-

cate that fractional photothermolysis is effective in

treating fine wrinkles and epidermal dyschromia, and

in remodeling acne scars.23, 24

Fine rhytides improve

over time.The improvement in pigmentation is related

to the concept of MEND formation and extrusion. As

mentioned above, this microscopic epidermal necrotic

debris refers to a column of photocoagulated epider-

mis ranging from 80 to 150 µm in diameter, which

sloughs off 3–7 days post treatment. MEND has a high

melanin content when examined histologically – a fact

that may explain improvement in skin pigmentation.

Patients typically need three to five treatment sessions

every 2–4 weeks. Besides the face, common treatment

areas include the neck, chest, and hands. One distinc-

tion between fractional photothermolysis, IPL, and

Q-switched laser technology is that its 1550 nm

wavelength laser largely targets tissue water and not

melanin. Improvement in pigmentation is a byproduct

of general resurfacing and is not pigment-specific.


Fig.10.10 Poikiloderma

of the neck and chest is

improved after five sessions

with the Fraxel laser:

(a) before; (b) after treatment.

(Photographs courtesy of

Richard Fitzpatrick MD.)

a b


ACTINIC PURPURA

Actinic purpura is a benign clinical entity resulting from

sun-induced damage to the connective tissue of the der-

mis.25

It is characterized by ecchymoses on the extensor

surfaces of the forearms and the dorsa of the hands that

usually last 1–3 weeks. It is an extremely common find-

ing in elderly individuals, occurring in approximately

11.9% of those older than 50 years. Its prevalence

markedly increases with years of exposure to the sun.

The effects of chronic sun exposure with the resultant

UV-induced skin changes occur more often and are more

pronounced in fair-skinned individuals than in others.

The purple macules and patches of this condition

occur because red blood cells leak into the dermal tis-

sue.This extravasation is secondary to the fragility of

the blood vessel walls caused by UV-induced dermal

tissue atrophy. This atrophy renders the skin and

microvasculature more susceptible to the effects of

minor trauma and shearing forces. The insult to the

skin is typically so minor that isolating it as a cause of

the ecchymoses can be difficult. Notably, no inflamma-

tory component is found in the dermal tissue. The

absence of a phagocytic response to the extravascular

blood has been postulated to be responsible for delay-

ing resorption for as long as 3 weeks.

Given its self-limited course, actinic purpura does

not require extensive medical care.To prevent further

UV-induced damage to the skin, sunscreens that pro-

vide both UVA and UVB protection should be applied

daily, especially to areas affected by the purpuric

lesions. Patients should also use barrier protection

(e.g., clothing).

To date, lasers have not been described as a treatment

for purpura, probably because of its self-limited course.

However laser-mediated photorejuvenation techniques,

both ablative (CO2

and Er:YAG lasers) and nonablative,

can induce dermal collagen remodeling and may

theoretically prevent the formation of actinic purpura in

photodamaged skin by strengthening tissue collagen.

CONCLUSIONS

The past 20 years has witnessed a dramatic revolution in

the approach taken by dermatologists in the treatment

of pigmentation induced by photoaging. Prior to

the advent of lasers, most therapies, including topical

preparations, could only target pigment in the epider-

mis, making it difficult to treat those lesions where the

responsible pigment lay deeper in the upper to mid-

dermis. Although certain technologies such as the CO2

and Er:YAG lasers could induce dermal collagen remod-

eling to combat rhytides and solar elastosis in addition to

treating dermal pigmentation, they could only do so at

the expense of epidermal ablation and damage. Newer

technologies such as IPL, the Q-switched lasers, and

fractional photothermolysis allow less ablative and more

targeted treatment of dermal pigmentation, which

translates into fewer treatments with shorter recovery

times and fewer side-effects such as hyper/hypopigmen-

tation. As our understanding of these technologies

evolves, we may better address the cosmetic and

psychosocial concerns of our growing aged population.

REFERENCES

1. Stern RS. Clinical practice. Treatment of photoaging.

N Engl J Med 2004;350:1526–34.

2. Holman CDJ, Evans PR, Lumsden GJ, Armstrong BK.

The determinants of actinic skin damage: problems of

confounding among environmental and constitutional

variables.Am J Epidemiol 1984;120:414–22.

3. American Society of Aesthetic Plastic Surgery. Cosmetic

Surgery National Data Bank. 2002 Statistics. New York:

ASAPS Communications. at http://www.surgery.org./

press/statistics-2002.asp (accessed 12 November 2006).

4. Ortonne JP, Pandya AG, Lui H, Hexsel D. Treatment of

solar lentigines. J Am Acad Dermatol 2006;54(5 Suppl

2):S262–71.

5. Kopera D, Hohenleutner D, Landthaler H. Quality-

switched ruby laser treatment of solar lentigines and

Becker’s nevus: a histopathological and immunohisto-

chemical study. Dermatology 1997;194:338–43.

6. Kilmer SL, Wheeland RG, Goldberg DJ, Anderson RR.

Treatment of epidermal pigmented lesions with the fre-

quency doubled Q-switched (532 nm) Nd:YAG laser: a

controlled single-impact, dose–response multicenter

trial.Arch Derm 1994;130:1515–19.

7. Tse Y, Levine VJ, McClain SA, Ashinoff R. The removal

of cutaneous pigmented lesions with the Q-switched

ruby laser and the Q-switched neodymium:yttrium–

aluminum–garnet laser. A comparative study. J Dermatol

Surg Oncol 1994;20:795–800.



8. Schmults CD,Wheeland RG. Pigmented lesions and tat-

toos. In: Goldberg DJ, Dover JS, Alam M, eds, Lasers and

Lights, Vol 3. Philadelphia: Elsevier Saunders, 2005:

41–66.

9. Chan HH, Fung WK,Ying SY, Kono T. An in vivo trial

comparing the use of different types of 532 nm Nd:YAG

lasers in the treatment of facial lentigines in oriental

patients. Dermatol Surg 2000;26:743–90.

10. Jang KA, Chung EC, Choi H, et al. Successful removal of

freckles in Asian skin with a Q-switched alexandrite laser.


11. Todd MM, Rallis TM, Gerwels JW, Hata TR. A compari-

son of three lasers and liquid nitrogen in the treatment of

solar lentigines.Arch Dermatol 2000;136:841–6.

12. Manstein D, Herron GS, Sink RK, et al. Fractional pho-

tothermolysis: a new concept for cutaneous remodeling

using microscopic patterns of thermal injury. Lasers Surg

Med 2004;34:426–38.

13. Rokhsar CK,Tse Y, Lee S, Fitzpatrick RE.The treatment

of photodamage and facial rhytides with Fraxel (fractional

photothermolysis). Lasers Surg Med 2005;36(Suppl

17):21–42(abst).

14. Calderone DC, Fenske NA. The clinical spectrum of

actinic elastosis. J Am Acad Dermatol 1995;32:1016.

15. Fisher GJ, Kary S,Vasani J, et al, Mechanisms of photo-

aging and chronological skin aging. Arch Dermatol

2002;138:1462–70.

16. Fisher GJ, Datta SC,Talwar HS, et al. Molecular basis of

sun-induced premature skin aging and retinoid antago-

nism. Nature 1996;379:335–9.

17. Goldberg DJ. New collagen formation after dermal

remodeling with an intense pulsed light source.


18. Kim KH, Rohrer TE, Geronemus RG. Vascular lesions.

In: Goldberg DJ, Dover JS, Alam M, eds. Lasers and

Lights, Vol 3. Philadelphia: Elsevier Saunders, 2005:

11–27.

19. Haywood RM, Monk BE. Treatment of poikiloderma of

Civatte with the pulsed dye laser: a series of seven cases.


20. Meijs M, Blok F, de Rie M.Treatment of poikiloderma of

Civatte with the pulsed dye laser: a series of patients with

severe depigmentation. J Eur Acad Dermatol Venereol

2006;20:1248–51.

21. Goldman MP, Weiss RA. Treatment of poikiloderma of

Civatte on the neck with an intense pulsed light source.

Plast Reconstr Surg 2001;107:1376–81.

22. Weiss RA, Goldman MP,Weiss MA.Treatment of poikilo-

derma of Civatte with an intense pulsed light source.


23. Rokhsar C, Fitzpatrick RE. The treatment of melasma

with fractional photothermolysis: a pilot study. Dermatol

Surg 2005;31:1645–50.

24. Rokhsar CK, Lee S, Fitzpatrick RE. Review of photoreju-

venation: devices, cosmeceuticals, or both? Dermatol

Surg 2005;31:1166–78.

25. Kalivas L, Kalivas J. Solar purpura. Arch Dermatol

1988;124:24–5.



INTRODUCTION

There are multiple types of vascular-related lesions

that can be treated with lasers.These include, but are

not limited to: hemangiomas, vascular malformations,

telangiectasias, rosacea, scar neovascularization, and

pyogenic granulomas. Currently, there are a number

of lasers available for the treatment of these vascular

lesions.These include lasers working at the following

wavelengths: 500, 532, 595–600, 940, and 1064 nm.

Some of these lasers can also be used to treat other

conditions, such as acne and lentigines.

Patients who present for treatment fall into two

main categories, based on their age. Adults often

present with a variety of vascular lesions or rosacea.

Children present for treatment of hemangiomas or

vascular malformations.Vascular lesions are relatively

common. Overall, vascular birthmarks affect approxi-

mately 8–10% of births, or nearly 400 000 new cases

in the USA alone per year.1

Adults will present with

either these lesions or acquired lesions, which have

appeared since childhood.

HEMANGIOMAS

Infantile hemangiomas are the most common benign

tumors occurring in infancy and childhood, being pre-

sent in about 2% of neonates. They are true tumors,

exhibiting the features of all neoplasms, such as

increased mitosis and hyperplasia. Although up to 30%

of these lesions may present at birth, they usually

become apparent in the first weeks of life.1–5

Congenital

hemangiomas are completely formed and present at

birth, and have a natural history and prognosis very

different from those of infantile hemangiomas.There

are additional, rarer related vascular birthmarks, which

are beyond the scope of this chapter.6,7

More than 60%

of infantile hemangiomas occur in the head and neck,

predominantly in Caucasians and somewhat less com-

monly in those of African or Asian descent. For unclear

reasons, female neonates are more likely to be affected

than males in a 3–5:1 ratio.They also seem to be more

common in premature infants; increased prevalence

correlates with both decreasing gestational age and

birthweight.8,9

Although most hemangiomas occur spo-

radically, familial inheritance in an autosomal dominant

fashion has been found.10

Recently, infantile hemangiomas have been linked to

placental tissue. The leading hypotheses for the etiol-

ogy of these lesions is the metastasis and implantation

of placental cells or placental precursor cells into areas

of high blood flow in the neonate, such as the head and

neck region. Much is still unknown about the mecha-

nisms of these processes, however, the link between

placental and hemangioma cells is irrefutable.11

Hemangiomas always increase in size by prolifera-

tion (hyperplasia) during the first year of life, and

involve skin, mucosa, and subcutaneous tissues to dif-

ferent degrees. Cutaneous hemangiomas may involve

only papillary dermis (superficial), deeper layers of the

skin or subcutaneous tissues (deep), or both (com-

pound). They may be focal, well-defined lesions or

segmental, involving dermatome-like segments of

skin.There seem to be generalized sites of predilection

on the face.12

The period of proliferation typically

ends within the first 4–8 months, although, rarely, it

can last up to 12–14 months.The end of proliferation

marks the beginning of the involutional phase. During

this phase, which may last for years, the hemangioma

undergoes varying amounts of regression in size and

11. Management of vascular lesions

Marcelo Hochman and Paul J Carniol


replacement with fibrofatty tissue over a variable

period of time. Approximately 30–40% of heman-

giomas involute to a cosmetically and functionally

acceptable point and do not require any treatment.

Intervention is necessary, and sought by patients, for

the remaining majority of cases, even after waiting

more than 7 years, and is dependent on multiple fac-

tors, such as size, anatomical location, age of the child,

and others.13

After involution is complete, superficial

hemangiomas leave an atrophic scar with a variable

degree of telangiectasia, deep hemangiomas leave a

residual mass of fibrofatty tissue covered with a saggy

cutaneous envelope, and compound lesions show vary-

ing degrees of all the above features. Accurate diagno-

sis and treatment planning of hemangiomas is made

entirely on the basis of clinical history and physical

examination, with imaging studies rarely being needed

and of limited import. Terms such as ‘strawberry or

capillary angioma’ or ‘cavernous hemangioma’ and

others are of historic and folkloric interest, and should

not be used when communicating about these lesions.

VASCULAR MALFORMATIONS

In contrast to hemangiomas, vascular malformations5 are

always present at birth (although they may not be appar-

ent), enlarge by hypertrophy, never proliferate, and

never involute.They are true developmental anomalies,

not tumors, and their rate of hypertrophy, and hence

their functional and cosmetic significance, is extremely

variable. Vascular malformations may originate from

capillaries, veins, venules, lymphatics, arterioles, or any

combination of these structures.They may involve skin,

subcutaneous tissues, and mucosa. They may also be

superficial, deep, compound, as well as focal or diffuse as

hemangiomas. Capillary malformations are superficial,

pink macules previously known as salmon patch, angel’s

kiss, or stork bite.They most commonly involve the mid-

line of the nape of the neck, followed by the forehead.

Although they are classified as vascular malformations,

these lesions typically do fade with advancing age and are

of passing significance.Venular malformations, known as

portwine stains, are important lesions made up of ectatic

postcapillary venules.Although they may present as flat,

pink macules at the beginning of life, they usually darken

and thicken with advancing age, forming a cobblestone

appearance as the dermal vessels continue to dilate

under the constant hydrostatic pressure. Thus, these

lesions enlarge over time by increasing the size of the

involved vessels, not by increasing the number of vessels.

Their distribution patterns seem to correspond to

dermatomes, and the presumed etiology is deficient or

inefficient postcapillary venule innervation.14

Venous

malformations composed of ectatic veins are usually

seen in the lips, the tongue and floor of the mouth, the

buccal fat space, and other mucosa.Patients frequently

complain of swelling with dependency, pain, limited

function of the affected region, and cosmetic deformity.

Superficial lesions are visible as purple masses,

whereas deeper lesions present as bluish or colorless

subcutaneous masses. Arteriovenous malformations are

rare vascular lesions originating from arteriovenous

channels that failed to regress during fetal develop-

ment.15

A palpable mass with an obvious well-developed

arterial supply and dilated tortuous veins are typical

features.A murmur may be heard or a thrill may be pal-

pated over the mass.These must be differentiated from

arteriovenous fistulas, which are usually precipitated by

trauma.

In contrast to hemangiomas, imaging studies are of

frequent use for establishing an accurate diagnosis and

planning of treatment. Magnetic resonance imaging

(MRI), angiography, and ultrasound are important diag-

nostic tools, and the particulars of differentiating these

lesions have been well described.16

Lymphatic malfor-

mations (previously known as cystic hygromas) are

dilated lymphatic channels arising from congenital

blockage or arrest of the normal development of the pri-

mordial lymphatic plexus.Although they grow at a slow,

steady rate, a sudden increase in size may be seen due to

infection, trauma, or hormonal changes. Over 80% of

the lymphatic malformations of the head and neck are

located in the cervical region, although they may also

involve the oral cavity, supraclavicular area, and parotid

gland.These can be divided into three categories. Some

lesions tend to be well defined, with macrocystic fea-

tures (>2 cm3), others tend to be interstitial, infiltrating

and poorly defined microcystic lesions (< 2 cm3), and

the third group consists of mixed lesions. Most lym-

phatic malformations are diagnosed in infancy, with up

to 90% being apparent by 2 years of age. Currently,

MRI is the diagnostic tool of choice.



TREATMENT

Hemangiomas17,18

There is no accepted consensus on the treatment of

infantile hemangiomas although the prevailing trend is

to intervene rather than follow the old dictum of

benign neglect (‘leave it alone, it will go away’).

Often, the proliferation of the hemangioma can be

stopped with early treatment with a vascular laser.

Furthermore, the vast majority of hemangiomas invo-

lute incompletely and leave a cosmetic defect necessi-

tating intervention regardless of how long patients are

willing to wait. Additionally, the psychological litera-

ture has documented the effects of facial differences on

self-image.‘Success in life’ has been found to correlate

with facial self-image of children between the ages of 2

and 5 years.19,20

The goal of therapy in young children is to optimize

the chance of normal facial appearance and function by

elementary school age. Limited hemangiomas that are

not on the face have not been shown to have an effect

on self-image. Treatment for hemangiomas varies,

depending on anatomical site, functional and cosmetic

significance, depth, complicating factors (i.e., ulcera-

tion or visual axis impingement), and whether the

lesion is proliferating or involuting.

As for most medical problems, hemangioma man-

agement decisions are made after analyzing the risks as

well as the potential benefits. For most cutaneous

hemangiomas, the greatest risk is bleeding if the lesion

is traumatized. However, depending on location,

hemangiomas can cause visual field obstruction or be at

risk for causing airway obstruction. Since these are sig-

nificant risks due to the lesion, they usually outweigh

the risks of therapy.

One approach to deciding whether to treat a

hemangioma is to ask the question: ‘Can we get a

result now with this (particular) treatment that is at

least as good as if we observe the lesion and allow it to

follow its known and presumed natural course?’ If the

answer is yes, then that specific intervention is justified

at that time. If the answer is no at that time, then

observation is continued until a predetermined point

of re-evaluation.

Serial observation is an active treatment option

and very different than telling the parents to wait an

indeterminate number of years for the hemangioma to

‘go away’ – particularly as some hemangiomas will

never completely regress, and even with regression

there can be sequelae. In addition to observation, dur-

ing the proliferative period, treatment can include

steroid therapy, laser treatment, surgical excision, or

combination therapy.

Lasers play an important role in the treatment of

cutaneous hemangiomas.21

Frequently, early treatment

of a proliferating hemangioma will either slow or

cease proliferation. In some cases, this will even lead

to early regression of the lesion, thereby minimizing

the chance of scarring or other problems. (Fig. 11.1).

Even hemangiomas that have thickened and are still

actively growing will respond to vascular laser therapy

Management of vascular lesions 127

Fig.11.1 This young child presented with an proliferating

superficial hemangioma,which involved the external nasal

skin and extended into the nostril opening. It was treated

with a 595 nm laser and had an excellent response.After the

first treatment, it stopped proliferating and regressed with

subsequent treatments. (Photograph courtesy of Paul J

Carniol MD.)


(Fig. 11.2). After initial laser therapy, any residual

lesion can be treated with lasers or surgical interven-

tion if or as needed in the future.

From infancy until over a year of age, this can fre-

quently be performed without the use of general anes-

thesia. These hemangiomas are usually treated with

a 595 nm flashlamp-pumped dye laser (VBeam,

Candela, Wayland, MA). Recently, a device has

become available that employs both a 595 nm laser and

a 1064 nm laser (Cynergy, Cynosure,Westford, MA).

As well as allowing separate use of the lasers, this

device can also be used in multiplex sequential laser

mode to treat vascular lesions.With this technology, it

can be used not only to treat 595 nm laser-responsive

lesions, but also to treat lesions that are resistant or

minimally responsive to the 595 nm laser. This offers

an advantage in treating hemangiomas and resistant

venular vascular malformations (‘portwine stains’).

Rapidly proliferating hemangiomas that pose a func-

tional or serious cosmetic threat can be treated with

systemic corticosteroids, although there is a lack of

consensus on their use.This lack of consensus is due to

the potential for significant sequelae from corticos-

teroid therapy. Furthermore, corticosteroids are only

useful during proliferation.Therefore, their use needs

to be carefully justified, and serial observation in

cooperation with the child’s pediatrician is necessary.

At present, a dose of 4 mg/kg/day oral prednisone or

prednisolone for a period of 4–6 weeks and tapered

over 2 weeks is frequently employed. If there is no

response within the initial 2 weeks of treatment, the

steroid should be tapered over 1 week and discontin-

ued. These protocols may change in the future.

Therefore, we recommend that, before initiating

therapy, practioners should review the most recent

therapeutic recommendations and the criteria for uti-

lization. Appropriate patient evaluation and determin-

ing whether corticosteroids are indicated should be

undertaken prior to initiating this therapy.

Although 75% of patients respond significantly to

this regimen, rebound growth may occur as the corti-

costeroid dose is tapered. If this occurs, then the low-

est dose that maintains proliferation in check should

be maintained for an additional 3–4 weeks and then

tapered again. The patient should be followed cau-

tiously by a pediatrician and monitored for the possible

side-effects of steroid treatment. Long-term compli-

cations have not been observed, and justify the use of

the drug in appropriate cases.22

Intralesional steroid

injections are useful for a limited group of very well-

defined, focal, deep, and occasionally compound

hemangiomas.

We use an injection mixture of triamcinolone

(40 mg/ml) and betamethasone (6 mg/ml)8

in very

select cases of parotid, eyelid, and midcheek lesions.

We do not inject auricular or nasal tip hemangiomas,


Fig.11.2 This child presented with a proliferating hemangioma of the left malar region (a).She had an excellent response to a

series of treatments with a 595 nm laser (b). (Photographs courtesy of Paul J Carniol MD.)

a b


since steroid injection can be associated with weakening

of the supporting cartilages and white plaque deposits

can be seen through the thin soft tissue envelope.The

goal of depot injections is to slow proliferation of the

deep component. Great care must be taken when

using lasers to treat injected lesions, as there appears

to be a higher risk for ulceration, particularly in the

malar area (personal observations by one of the

authors (MH) from 1990 to the present).

If the lesion is life-threatening or does not respond

to steroid therapy, other medications such as vin-

cristine can be considered. Although initially the first

choice for these difficult situations, interferon in

children under the age of 1 year should be used very

cautiously because of the associated high incidence

of spastic diplegia now recognized. Due to this

risk, many centers will not use interferon therapy.

Other medications, such as imiquimod, a topical

immunomodulator, may prove useful for controlling

proliferating hemangiomas, although controlled stud-

ies are still needed to confirm its efficacy in humans.

Recently, intralesional bleomycin has been advocated

in the treatment of proliferating hemangiomas,

although again further experience is needed to validate

its use.23,24

Before initiating systemic therapy, it is

important for each physician to review the current

recommendations for such therapy.

Surgical management of hemangiomas is integral to

the overall treatment algorithm.17,18,25

Historical mis-

givings and misconceptions about the operability of

these lesions have been supplanted by experience and

better understanding. Surgical planes exist (between

the hemangioma and surrounding structures) or can

be created (between the superficial and deep compo-

nents or within the deep component). Hemangiomas

are solid tumors with few, isolated feeding vessels.

Therefore, meticulous technique and the use of rou-

tine micro-unipolar and bipolar devices makes their

dissection virtually bloodless. Conservatism is critical

when resecting facial tissue in children, and the use of

flaps and grafts is avoided as far as possible.

The goal is to resect enough tissue and achieve

primary closure of the skin.We avoid the use of flaps

and grafts. However, in complicated cases, due to the

extent of the lesion, primary closure may not be possi-

ble. Subtotal excision of the deep component to pre-

serve contour or to set the stage for a further resection

is common. Every effort is made to obtain a functional

and cosmetic result before school age to minimize the

potential for psychological sequelae.

When considering surgery, the risks of the proce-

dure, including the risk of possible postoperative

morbidity, should be considered. Our threshold for

excision of nasal tip and periorbital lesions, with a

significant associated deformity, is lower than for other

sites, because of the obvious severe potential func-

tional and cosmetic sequelae. If the potential benefits

of surgical excision (e.g., cosmetic improvement and

parents’ peace of mind) outweigh the potential risks,

lesions at other sites can also be excised during the

proliferative phase. Once the phase of proliferation is

ended, the progression of involution of the lesion may

be observed for a few months. If there is no significant

involution, then treatment should be considered based

on the previously discussed principles.

If the lesion undergoes involution, lasers and other

modalities can be used to treat atrophic scarring,

telangiectasia, and residual subcutaneous fibrofatty

tissue. Atrophic scarring can be treated with carbon

dioxide (CO2) or erbium laser skin resurfacing. More

recently, a fractionated CO2

laser has become available

that also can be used to treat this scarring (Active Fx,

Lumenis, Santa Clara, CA). Residual telangiectasias

can be treated with a vascular laser (VariLite, Iridex,

Mountain View, CA; Cynergy, Cynosure, Westford

MA; VBeam, Candela, Wayland, MA). Residual sub-

cutaneous fibrofatty tissue can be excised and sculpted

to obtain better contours.

Capillary and venular vascular

malformations

Vascular malformations can vary in size and location,

from small limited vascular malformations (Fig.11.3)

to extensive malformations, with intracranial involve-

ment such as Sturge–Weber syndrome.

Laser therapy is the preferred method of treatment for

capillary and venular vascular malformations (‘portwine

stains’). There are now a number of lasers that can

potentially be used to treat these lesions (see the lasers

listed above for hemangiomas). Start-safe parameters

are used for the initial laser pulses to evaluate the clini-

cal response and set the stage for further treatments.26



Once the response to the initial laser pulses has been

assessed, the laser parameters can be adjusted.

Portwine stains are typically treated every 4–6

weeks. The therapeutic endpoint is clearance of the

lesion, diminished response to therapy, or the patient

deciding that the improvement has reached their

personal goal.

Venular vascular malformations do not grow new

vessels after birth. However, due to the hydrostatic

pressure, over time, the blood vessels involved in these

malformations increase in diameter. Therefore, after

laser therapy, even if the residual vessels are not clini-

cally apparent, over time they may become visible due

to increased diameter. Thus, at some time in the

future, some of these patients will redevelop visible

lesions that will require retreatment.Thickened, ‘cob-

blestoned’, or purple vascular malformations may not

respond to treatment with a 595 nm laser alone.

However, these lesions may respond to ‘multiplex’

therapy with the sequential 595 nm–1064 nm Cynergy

laser. Some of these lesions have also responded

to careful treatment with a neodymium : yttrium

aluminum garnet (Nd:YAG) laser.

Venous malformations

Venous malformations can be treated with laser photo-

coagulation, sclerotherapy, or surgical resection,

depending on the depth, extent, and location of the

lesion. Due to their blue color, these may not respond to

traditional vascular lasers. However, superficial lesions

or the superficial component of compound lesions can

be treated with a sequential 595 nm–1064 nm laser

(Cynergy) or with judicious use of an Nd:YAG laser.

Laser photocoagulation diminishes the vascularity

of the overlying skin or mucosa, which can then be

preserved if surgical resection of the deeper compo-

nent is performed.The deep component of the lesion

should be resected carefully because of the risk of

bleeding due to extremely fragile ectatic vessels. In

contrast to hemangiomas – and probably the source of

misgivings about the role of surgery for vascular

lesions – hemostasis during these procedures can be

quite challenging. Tedious dissection and hemostasis

with vascular clips, peripheral transcutaneous

sutures, and topical hemostatic agents are employed

to varying degrees. Preparation for blood transfusions

should be made preoperatively. Resection of the cuta-

neous component is imperative to prevent recur-

rence. Sclerotherapy and embolization are viable

alternatives in the treatment of venous malforma-

tions. They are also useful as pre- and postoperative

adjunctive treatment.

Sclerotherapy involves a percutaneous puncture into

the malformation, and, under fluoroscopic guidance,

an irritant is injected into the malformation to promote


Fig.11.3 (a) This young woman had a limited venular vascular malformation of the left side of her neck. (b) She responded

well to two treatments with a vascular laser with complete clearing of the visible lesion. (Photographs courtesy of

Paul J Carniol MD.)

ba



clotting, inflammation, and eventually fibrosis of the

lesion. It is important to note that sclerotherapy can

require repeated treatments to maintain control of the

lesion, and usually is not considered curative as the

lesion may eventually re-expand. Sclerosing agents,

such as absolute ethanol, sodium tetradecyl sulfate,

sodium morrhuate, polidocanol, sclerosant foam, and

ethanolamine, have been reported in the treatment of

venous malformations.27

Injection of sclerosing agents has significant associ-

ated risks in the upper two-thirds of the face. The

veins in the head and neck region lack valves.

Therefore, the injection of sclerosing agents in the

upper and middle third of the face can cause cav-

ernous sinus thrombosis. The amount of sclerosing

agent depends on the agent itself and the extent of

venous malformation, but, as a rule, it should not

exceed 1 ml/kg of body weight. If the lesion is exten-

sive and more than one treatment is necessary, they

should be spaced at 4- to 6-week intervals.

Arteriovenous malformations

Treatment with laser, steroids, or irradiation has

not been effective in the management of arterio-

venous malformations.The most effective treatment

of these lesions is complete surgical excision of

the lesion with clear margins, followed by immedi-

ate reconstruction. If the lesion is extensive, then

combined treatment consisting of highly selective

embolization followed by complete resection within

the next 24–48 hours is indicated. The natural pro-

gression of the lesion is inexorable growth over

time. Therefore, the main goal of surgery should be

complete eradication of the nidus, with clear mar-

gins to prevent recurrence. The sacrifice of struc-

tures involved by the arteriovenous malformation

(e.g., mandible, facial nerve, and muscles of mastica-

tion) may be a necessary part of the procedure. The

surgical and anesthetic team must be prepared to

replace with blood products, and cell-saver technol-

ogy may be helpful in the most difficult cases.

Resection and reconstruction of these and other

malformations is more akin to traditional head and

neck cancer procedures than those for infantile

hemangiomas.

Lymphatic malformations

Surgical excision is the preferred treatment modality

for lymphatic malformations. Because of the difficulty

of distinguishing involved tissue from normal tissue,

complete resection of lesions with microcystic infil-

trating features is not always possible. Lesions with

well-defined macrocystic features are more likely to

be resected completely. Superficial mucosal lesions can

be treated with the CO2

laser using 20 W continuous

mode until sufficient depth of destruction is obtained.

The wound is then left to heal by second intention.

Extensive lesions involving both mucosa and deep soft

tissue may need to be treated with a combined

approach. Recurrence after ‘total’ resection of macro-

cystic lesions is probably due to infiltrating features of

the lesions at the interface with normal tissues. Mass

reduction with needle aspiration is reserved for cases

with a threatened airway. OK-432 (a lyophilized mix-

ture of a low-virulent group A Streptococcus pyogenes

incubated with penicillin G) is not yet approved for

general use in the USA, but has been used extensively

in Europe and Japan, with results showing up to 96%

complete response in macrocystic lesions. Bleomycin

has also been used, with similar results. Overall, the

literature continues to support good results with

sclerotherapy in patients with macrocystic disease

only, which is the same entity that traditionally also

responds well to surgery. Patients with microcystic

disease, especially if it is extensive, will likely require

multiple therapies to help control and alleviate their

symptoms.28,29

Facial telangiectasias and rosacea

Many adults are unhappy with their facial telangiec-

tasias. These frequently appear around the nasal ala,

nasal tip, nasal dorsum, chin, and cheeks (Fig. 11.4).

The majority of these will respond to treatment with a

vascular laser. For some of these lesions, the response

to a particular laser wavelength varies with the diame-

ter of the involved vessel.30

Larger-diameter vessels

frequently will have a better response to a 940 nm

laser than to a 532 nm laser.

Besides medical therapy, the redness of rosacea can

also be treated with a vascular laser. Patients are often


very pleased with the lightening and decreased redness

from laser therapy.

CONCLUSIONS

Correct diagnosis is the major factor in successful

treatment of vascular lesions of the head and neck.

Hemangiomas must be differentiated from vascular

malformations because of the therapeutic implica-

tions. Steroids, lasers, and surgical excision all have a

place in the management of these lesions. As more

information is gained about the pathophysiology of

these lesions, the management schema will continue

to evolve.

ACKNOWLEDGMENT

This work was supported is part by The Hemangioma

Treatment Formulation (www.hemangiomatreatment.

org).

REFERENCES

1. Marler J, Mulliken J.Vascular anomalies – classification,

diagnosis and natural history. Facial Plast Surg Clin North

Am 2001;9:495–504.

2. Mulliken JB, Fishman SJ, Burrows PE. Vascular

anomalies. Curr Probl Surg 2000;37:519–84

3. Mulliken JB, Glowacki J. Hemangiomas and vascular mal-

formation in infants and children: a classification based on

endothelial characteristics. Plast Reconstr Surg 1982;

69:412–20.

4. Bauland CG, van Steensel MA, Steijlen PM, Rieu PN,

Spauwen PH. The pathogenesis of hemangiomas: a

review. Plast Reconst Surg 2006;117:29e–35e.

5. Waner M, Suen J. Hemangiomas and Vascular

Malformations of the head and Neck. New York:Wiley-

Liss, 1999.

6. Krol A, MacArthur CJ. Congenital hemangiomas. Arch


7. Mulliken JB, Enjolras O. Congenital hemangiomas

and infantile hemangiomas: missing links. J Am Acad

Dermatol 2004;50:875–82.

8. Powell TG, West CR, Pharoah PO, Cooke RW.

Epidemiology of strawberry hemangioma in low birth-

weight infants. Br J Dermatol 1987;116:635–41.

9. Amir J, Mezker A, Krikler R, Reisner SH. Strawberry

hemangioma in preterm infants. Pediatr Dermatol

1986;3:331–2.

10. Blei F,Walter J, Orlow SJ, Marchuk DA. Familial segrega-

tion of hemangiomas and vascular malformations as an

autosomal dominant trait. Arch Dermatol 1998;134:

718–22.

11. Phung TL, Hochman M, Mihm M. Current knowledge of

the pathogenesis of infantile hemangiomas. Arch Facial

Plast Surg 2005;7:319–21.

12. Waner M, North P, Scherer KA, Frieden IJ.The non-ran-

dom distribution of facial hemangiomas. Arch Dermatol

2003;139:869–75.

13. Williams EF 3rd, Starislaw P, Dupree M, et al.

Hemangiomas in infants and children: an algorithm for

intervention.Arch Facial Plast Surg 2000;2:103–11.

14. Smollen BR, Rosen S. Port wine stains: a disease of

altered neural modulation of blood vessels? Arch

Dermatol 1986;122:177–9.

15. Kohout MP, Hansen M, Pribaz JJ, Mulliken JB.

Arteriovenous malformations of the head and neck:

natural history and management. Plast Reconstr Surg

1998;102:643–54.

16. Buckmiller L. Update on hemangiomas and vascular

malformations. Curr Opin Otolaryngol Head Neck

Surg 2004;12:476–87.


Fig.11.4 (a) This patient was unhappy with nasal and cheek telangiectasias. (b) After treatment with a 532 nm and 940 nm

laser (VariLite, Iridex,Mountain View,CA) she had a significant improvement in her telangiectasias. (Photographs courtesy of Paul

J Carniol MD.)

ba


17. Hochman M, Williams EF. Management of cutaneous

hemangiomas. Facial Plast Surg Clin North Am 2001;

9:621–8.

18. Hochman M, Mascareno A. Management of nasal heman-

giomas.Arch Facial Plast Surg 2005;7:295–300.

19. Lande RG, Crawford PM, Ramsey B. Psychosocial impact

of vascular birthmarks. Facial Plast Surg Clin North Am

2001;9:561–7.

20. Williams EF 3rd, Hochman M, Rodgers BJ, et al. A psy-

chological profile of children and families afflicted with

hemangiomas.Arch Facial Plast Surg 2003;5:220–34.

21. Thomas RT, Hornung RL, Maaning SC, Perkins JA.

Hemangiomas of infancy: treatment of ulceration. Arch


22. Boon L, MacDonald DM, Mulliken J. Complications of

systemis corticosteroid therapy for problematic heman-

giomas. Plast Reconst Surg 1999;104:1616–22.

23. Adams D. The non-surgical management of vascular

lesions. Facial Plast Surg Clin North Am 2001;9:601–8.

24. Pienaar C, Graham R, Geldenhuys S, Hudson DA.

Iatralesional bleomycin for the treatment of hemangiomas.

Plast Reconst Surg 2006;117:221–6.

25. Balniji RK, Buckingham E, Williams EF. An aesthetic

approach to facial hemangiomas. Arch Facial Plast Surg

2005;7:301–6.

26. Kelly KM, Choi B, McFarlane S, et al. Distribution and

analysis of treatment for port-wine stains. Arch Facial

Plast Surg 2005;7:287–94.

27. Deveikis JP. Percutaneous ethanol sclerotherapy for vas-

cular malformations in the head and neck. Arch Facial

Plast Surg 2005;7:322–5.

28. Fujino A, Moriya Y, Kitajima M, et al. A role of cytokines

in OK-432 injection therapy for cystic lymphangioma: an

approach to the mechanism. J Pediatr Surg 2003;38:

1806–9.

29. Banieghbal B, Davies MRQ. Guidelines for the successful

treatment of lymphangioma with OK-432. Eur J Pediatr

Surg 2003;13:103–7.

30. Carniol PJ, Price J, Olive A.Treatment of telangiectasias

with the 532 nm and the 940/532 nm diode laser. Facial

Plastic Surg 2005;21:117–19.



INTRODUCTION

Hair is a physical characteristic that helps distinguish

each one of us as individuals. The color, length, and

texture of hair on our scalp are among the few physical

characteristics that we can control. Hair frames our

face. A full head of hair makes any individual appear

more youthful. Millions of people try to maintain their

hair with medication and surgery.1

While a positive physical characteristic on the scalp,

eyebrows, and eyelashes, hair on almost every other part

of the skin is perceived as a negative physical attribute.

For decades, millions of people sought treatment to

remove unwanted hair. The majority of treatment

options resulted in a safe but temporary reduction of hair

requiring regular maintenance throughout life. In the

1990s, the most significant new treatment option to

permanently destroy hair was introduced: laser hair

removal.2

Laser hair removal is based on the theory of

selective photothermolysis.3

Selective photothermolysis has revolutionized the

therapeutic role of lasers in medicine. In the skin,

prior to removing hair, it was successfully applied

to treating unwanted vascular lesions, pigmented

lesions, tattoos and wrinkles.4–6

Laser hair removal

has become one of the most popular cosmetic proce-

dures over the past ten years. For millions of patients,

it has resulted in a long-term reduction in unwanted

hair. As with any procedure, appropriate candidate

selection and expectations are vital to its success.

Appropriate candidate selection, expectations, choice

of laser/light device, and the risks of the procedure

and how to minimize them are established during a

medical consultation.

THE CONSULT

All patients undergoing laser hair removal should have a

medical consultation before the procedure (Table 12.1).

For the vast majority of patients, unwanted hair is the

result of a combination of benign hormonal and genetic

factors. In a minority of patients, unwanted hair can be a

cutaneous sign of an underlying medical condition or a

side-effect of medication.7

A medical consultation is

needed to help distinguish between the two.

The target chromophore for laser/light sources

using selective photothermolysis is thought to be

melanin.8This is the reason current technology only

works on pigmented hair. Patients with blond, gray,

or lightly pigmented hair will see no improvement

from laser/light sources, and should not undergo

treatment. All skin types can undergo successful hair

removal.

Since melanin is the target chromophore, the risk of

cutaneous hyper- or hypopigmentation in darker skin

types is higher with shorter wavelengths such a

694 nm ruby, 755 nm alexandrite or 800 nm diode

lasers. Longer wavelengths with longer pulse dura-

tions such a 1064 nm long-pulse yttrium aluminum

garnet (YAG), penetrate deeper into skin relatively

12. Laser treatment for unwanted hair

Marc R Avram

Table 12.1 Candidate selection

Good candidate Poor candidate

Pigmented thick hair Unpigmented hair

All skin types Vellous hair

Realistic expectations Persistent sunburn

Unrealistic expectations


sparing epidermal pigment and reducing (but not

eliminating) the risk of hyper/hypopigmentation.9

The caliber of the hair follicle also helps determine

the success of the procedure. Thick hair tends to

respond better than thin vellous-like hair. In a small

minority of patients with a lot of vellous hair, a para-

doxical growth of hair may even occur.10

The reason

for this remains unknown. The laser works best on

follicles in an anagen phase of growth. This results in

the need for multiple treatments to achieve a clear

clinical hair reduction. Since follicles in the anagen

phase are the target, treatments should be spaced

between 4 and 12 weeks depending on the location on

the body.There is variability on how well each patient

will respond. Most patients will have a majority of

hair removed after 5–10 treatments. A minority will

have near complete removal and a small minority lit-

tle or no improvement. Patients should also be aware

of the potential need for future maintenance treat-

ments. It is unclear whether such maintenance treat-

ments are needed as a result of hair follicles emerging

from a prolonged laser-induced telogen phase or of

newly generated hair follicles. At the end of the con-

sult, patients should be encouraged to ask questions

or contact the office with any questions or concerns

prior to scheduling the procedure.The overwhelming

majority of patients with realistic expectations of

what lasers can and cannot due for removing hair will

be happy with their result.

PREOPERATIVE

All patients should be given a written informed con-

sent to review. Common potential side-effects, post-

treatment protocol, current medications, past medical

history, and questions regarding the procedure and

consent should be discussed. An active sunburn or

inflammatory dermatosis increases the risk of blister-

ing resulting in potential dyschromia or textural

changes in the skin. Sunscreen use and sun protection

prior to treatment and in the first 48 hours after treat-

ment need to be emphasized to lower the risk of side-

effects. A patient presenting to the office with a

sunburn or active inflammatory dermatosis should be

rescheduled.

The amount of pain associated with the procedure

is a reflection of the density and caliber of hair folli-

cles on the treated skin. Patients with thick, dense

hair will experience pain with the procedure, while

those with less density and finer hair will experience

less pain. The perception of pain varies from individ-

ual to individual. The majority of patients undergo

treatment with no anesthesia and tolerate the proce-

dure well. Some require or request a topical anes-

thetic to reduce discomfort. Topical anesthetics

should be used in safe quantities and as directed to

minimize the risk of lidocaine toxicity.11

Local anes-

thetics should not be used in the region to be treated

by a laser or light source, because the water in the

dermis from the local anesthetic will be heated by the

energy from the laser light, thereby increasing the risk

of a blistering reaction, dyschromia, and textural

changes in the skin.

THE PROCEDURE

Safety is paramount in the operation of all lasers (Fig.

12.1). Everyone in the procedure room should wear

protective shields or goggles. Hair should be trimmed

in the treated region to reduce the risk of epidermal

changes secondary to thermal injury of follicles above

the skin and to reduce the plume in the room. Careful

attention should be paid to treat the entire surface of


Fig.12.1 All individuals wear protective eye shields.


the desired treatment zone by slightly overlapping

each pulse (Fig. 12.2). It is vital that the appropriate

use of the laser and cooling device be followed to

reduce the risk of side-effects.12

Many lasers require

firm contact with the skin for optimal efficacy and

safety. Any operator of a laser should be thoroughly

trained in the appropriate technique.

Larger spot sizes will allow for a more rapid treat-

ment and greater penetration of energy into the skin,

and should be used wherever possible13

(Fig. 12.3).

Immediately following the treatment, erythema and

perifollicular edema are visible, which typically

resolve in 30–60 minutes (Fig. 12.4). Postoperative

instructions should be reviewed. Patients should be

encouraged to contact the office if there is any crust-

ing, blistering, dyschromia, pain after the procedure,

or any questions or concerns.

COMPLICATIONS

All medical procedures are associated with potential

side effects. Laser hair removal is no exception.

Every physician’s goal is to minimize any risk of side-

effects.The majority of complications can be avoided

by a proper physical examinations, medical history,

and appropriate preoperative instructions during

the consultation. Common side-effects includes

Laser treatment for unwanted hair 137

Fig.12.2 Poor cosmetic result secondary to lack of overlap

of spot size when treating the back.

Fig.12.3 Larger spot sizes allow greater penetration of

laser light.

Fig.12.4 Perifollicular edema immediately after

treatment.


transitory, crusting, superficial erosions and pseudo-

folliculitis and temporary dyschromia (Figs. 12.5 and

Table 12.2).

Unusual complications include permanent dyschro-

mia, scarring and paradoxical increased hair growth,

ocular damage from operator error, infection, and

vascular changes in the skin.

All patients should be encouraged to contact the

office and be seen as soon as possible if they believe they

are having any side-effects after a procedure. Rapid

medical intervention can often eliminate or substan-

tially reduce the long-term effects of a complication.

THE FUTURE

Currently, laser hair removal is a safe, effective proce-

dure.With appropriate candidate selection, expecta-

tions, and laser device, the vast majority of patients are

happy with the results.

A challenge remains to permanently remove unpig-

mented or lightly pigmented hair follicles. Several dif-

ferent technologies have been tried without consistent

effective long-term permanent reduction of hair.14

Photodynamic therapy may become a treatment

option. Effective, safe, affordable home devices may be

another development in the field over the next several

years. Ultimately, safe selective genetic manipulation

of hair follicles where we want and where we do not

want it on our skin will become a reality.

REFERENCES

1. Avram MR, Cole JP, Gandelman M, et al. The potential

role of monoxidil in hair transplantation setting. Dermatol

Surg 2002;28:894–900.

2. Grossman MC, Dierickx C, Farinelli W, Flotte T,

Anderson RR. Damage to hair follicles by normal-mode

ruby laser pulses. J Am Acad Dermatol 1996;35:889–94.

3. Anderson RR, Parrish JA. Selective photothermolysis:

precise microsurgery by selective absorption of pulsed

radiation. Science 1983;220:524–7.

4. Anderson RR, Margolis RJ,Watenabe S, et al. Selective

photothermolysis of cutaneous pigmentation by Q-

switched Nd:YAG laser pulses at 1064, 532, and 355 nm.


5. Astner S.Anderson RR.Treating vascular lesions. Dermatol

Ther 2005;18:267–81.

6. Bernstein EF. Laser treatment of tattoos. Clin Dermatol

2006;64:850–5.

7. Azziz R. The evaluation and management of hirsutism.

Obstet Gynecol 2003;101:995–1007.

8. Wanner M. Laser hair removal. Dermatol Ther 2005;

18:209–16.

9. Battle EF, Hobbs LM. Laser assisted hair removal for

darker skin types. Dermatol Ther 2004;17:177–83.

10. Alajlan A, Shapiro J, River JK, et al. Paradoxical hyper-

trichosis. J Am Acad Dermatol 2005;53:85–8.

11. Brosh-Nissimov T, Ingbir M,Weintal I, Fried M, Porat R.

Central nervous system toxicity following topical skin appli-

cation of lidocaine. Eur J Clin Pharmacol 2004;60:683–4.

12. Klavuhn KG, Green D. Importance of cutaneous cooling

during photothermal epilation: theoretical and practical

considerations. Lasers Surg Med 2002;31:97–105.

13. Baumler W, Scherer K,Abels C, et al.The effect of differ-

ent spot sizes on the efficacy of hair removal using a long-

pulsed diode laser. Dermatol Surg 2002;28:118–21.

14. Sadick NS, Laughlin SA. Effective epilation of white and

blond hair using combined radiofrequency and optical

energy. J Cosmet Laser 2004;6:27–31.


Fig.12.5 Dyschromia secondary to inappropriate power

and technique.

Table 12.2 Complications from laser hair removal

Common Unusual

Transitory acne/folliculitis Permanent dyschromia

Transitory crusting Scarring

Transitory dyschromia Paradoxical increase in hair

Ocular damage

Vascular changes

Viral or bacterial infection


INTRODUCTION

It is estimated that by the year 2010, the American

population will consist of 40.2 million people over the

age of 65.1This rise in the aging population has led to

an increase in the number of cosmetic procedures per-

formed each year. According to the American Society

for Aesthetic Plastic Surgery (ASAPS) 2006 statistics

report, nearly 11.5 million cosmetic procedures were

performed in the USA in 2005.2

In addition, there was

a reported increase in noninvasive procedures with

19% surgical and 81% nonsurgical procedures, being

performed in 2005.2

As is evident from these recent

statistics, cosmetic surgery has embarked on a new

trend toward less invasive procedures.The aging popu-

lation is looking for rejuvenation procedures that

deliver achievable results, yet with reduced downtime

and minimal risk profile. This movement in cosmetic

medicine has been away from invasive and destructive

processes and toward innovative technologies and

techniques that spare tissue and promote growth.

However, while these treatments have fewer side-

effects and decreased downtime, they often require

multiple treatments for comparable results. Improving

the appearance of the skin without injury to the epi-

dermis is the hallmark of nonablative skin rejuvena-

tion.This novel arena of rejuvenation monopolizes on

the intrinsic energies of nonablative laser, radiofre-

quency, and optical devices to treat a wide array of skin

afflictions, ranging from eliminating vascular and

benign pigmented lesions of the skin to improving

the appearance of photodamaged skin and rhytids.

Nonablative technologies, which have been successful

on the face and neck, are now being applied to the

body in the hope of eradicating some of the more

displeasing physical changes characteristic of aging,

such as striae distensae, cellulite, and fat, while having

the added capacity of contouring flaccid skin. Up until

recently, body rejuvenation therapy has been solely

contingent on invasive procedures, such as liposuc-

tion, abdominoplasty, reconstructive surgeries, and

ablative procedures as a means of returning the body’s

appearance to a more aesthetically pleasing ideal.

While achieving appreciable results, these procedures

are not without adverse effects, well-described mor-

bidities, significant downtime, and long-term sequelae

(pigmentary changes and scarring).With the increas-

ing amounts of clinical data and results from scientific

studies, the techniques of nonablative body rejuvena-

tion, producing safe and effective treatment for an

ever-growing aging population, are being refined.This

chapter summarizes the current data and the use of

noninvasive technologies for body rejuvenation.

STRIAE DISTENSAE

Striae distensae, known colloquially as stretchmarks,

were described as a clinical entity hundreds of years

ago, with the first histological description appearing in

the medical literature in 1889.3

Striae are common

cutaneous lesions that are cosmetically displeasing to

many patients. They are characterized by wide linear

bands of atrophic or wrinkled skin that occur in areas

of dermal damage secondary to stretching.The distrib-

ution of striae is quite variable, but typically involves

the abdomen, buttocks, breasts, and skin flexures.

Extremities, including the arms, thighs, and bicepital

areas, may also be involved. Women develop striae

more commonly than men, with studies showing that

13. NonInvasive body rejuvenation technologies

Monica Halem, Rita Patel, and Keyvan Nouri


70% of adolescent females and 40% of adolescent

males develop these lesions.4

The etiology of striae is still controversial and is

closely related to the variable clinical scenarios it

accompanies.They usually occur during diverse physi-

ological states, including pregnancy, adrenocortical

excess (long-term steroid therapy and Cushing’s syn-

drome), changes in body habitus, obesity, and rapid

weight gain.3,4

There is an association with sudden

changes in glucocorticoid levels, which commonly

occur during pregnancy or growth spurts of adoles-

cence. Striae are seen in 90% of pregnant women due

to a combination of hormonal factors along with

increased lateral stress on connective tissue.5

A recent

study of 161 women found that striae gravidum are

most likely to develop early in gestation, with peak

incidence occurring in the first and second

trimesters.6

Several studies have shown the pathogenesis of striae

to be related to changes among the dermal extracellu-

lar matrix components, including fibrillin, collagen,

and elastin, during stretching of the skin.7

Different

theories have been proposed with regard to what hap-

pens to these components during stretching, including

dermal collagen rupture, elastolysis, and mast cell

degranulation leading to elastic fiber changes and dis-

rupture of crosslinked collagen.7–9

In one study, Lee

et al10

found a possible genetic predisposition to striae.

They found a decreased expression of collagen and

fibronectin genes in striae distensae tissue.

The development of striae distensae can further be

seen as an evolution of both clinical and histological

changes. Initially, striae rubra represent thin, red to

pink, raised lesions that eventually enlarge in size and

acquire a vivid purple appearance. These fresh striae

show acute inflammatory changes, such as deep and

superficial lymphocytic infiltration accompanied by

dilated vasculature and edema of the upper dermis.

Over time, bundles of collagen and elastic tissues in

the reticular dermis disappear, leaving behind a much

thinner epidermis with attenuation of the rete ridges.

These striae are now more atrophic and scar-like, and

turn to white striae alba.11

The treatment of striae distensae has been challeng-

ing, and various modalities have been studied. These

include topical therapies such as topical tretinoin 0.1%

alone or in combination with 20% glycolic acid, as

well as the combination of 20% glycolic acid with 10%

L-ascorbic acid.12,13

Microdermabrasion has also been

added to these treatment regimens to enhance the

penetration of the topical therapies. These therapies

have yielded variable cosmetic results, working to pro-

ductively decrease redness and size of striae rubra but

having much less success in older, more atrophied

striae alba.14

Pulsed dye laser

The use of noninvasive laser devices to correct striae

distensae has gained popularity due to their reliability.

The pulsed dye laser was the first to be tried, based on

its success in treating hypertrophic and keloidal

scars.15–18

McDaniel et al19

showed that the 585 nm

flashlamp-pumped pulsed dye laser can be used to

treat striae.They treated 39 patients with striae using

this laser at four different fluence treatment protocols.

Results were evaluated using a combination of blinded

objective grading and skin surface analysis with optical

profilometry. Pulsed dye laser therapy was shown to

improve the appearance of the striae. In addition, the

optimal treatment fluence was determined to be

3 J/cm2

using a 10 mm spot size. Biopsies obtained

during this study found an increase in dermal elastin

content coinciding with the improvement of clinical

appearance.Further biopsies taken 8–12 weeks after

treatment showed a marked increase in elastin content

in the papillary and reticular dermis. McDaniel et al19

concluded that laser therapy for striae may produce

clinical improvement for up to 6–12 months post

treatment. Another study looking at the treatment of

mature striae with the pulsed dye laser confirmed the

histological changes in elastin.20

Five patients were

prospectively treated with the 585 nm pulsed dye laser

at 2-month intervals for 1–2 years.The response of the

striae was evaluated through sequential clinical, photo-

graphic, textural, and histological assessment. All five

patients showed clinical improvement, and serial biop-

sies of the striae 8 weeks post treatment revealed an

increase in dermal elastin that coincided with this clin-

ical improvement. Alster and colleagues21

conducted a

larger multicenter trial using the 585 nm flashlamp-

pumped pulsed dye laser at low energy settings to

treat striae. The patients were followed for 6 months



prospectively to determine the results of multiple

treatments and length of therapy.They concluded that

striae responded best to lower energy densities at

3.0 J/cm2, and that there was continued improvement

of appearance for as long as 6 months after a single

treatment. They further postulated that the improve-

ment may be due to the laser-induced effects on

hemoglobin, elastin, collagen, or other undiscovered

factors. Another study comparing the treatment of

striae rubra and striae alba using the 585 nm pulsed

dye laser on 29 patients for 12 weeks concluded that

the pulsed laser had a moderate beneficial effect in

reducing the degree of erythema in striae rubra; how-

ever, no effect of the laser on striae alba was found. It

was further found that the total weight of collagen per

gram of dry weight of sampled tissue increased in the

striae rubra treated with the pulsed dye laser as com-

pared with controls. A study using a copper bromide

laser (577 nm), with a similar wavelength to the pulsed

dye laser, treated 15 patients with striae and followed

these patients for 2 years post treatment.22

These

authors treated patients with skin types II–III with the

copper bromide laser at 4 J/cm2, with five sessions 1

month apart, with clinical improvement. A follow-up

at 2 years confirmed the stability of the results

achieved.

The use of the pulsed dye laser for the treatment of

striae distensae has been recommended with caution

or avoided in patients with skin types IV–VI. A study

comparing the 585 nm pulsed dye laser and the short

pulsed carbon dioxide (CO2) laser in the treatment of

striae distensae in skin types IV and VI observed

marked hyperpigmentation in darker skin types.23

It

was concluded that this was secondary either to the

inflammation created during the treatment or to the

hemoglobin-competing chromophore melanin at

the 585 nm wavelength.


Intense pulsed light (IPL) is another type of therapy

currently being used to improve stretch marks. IPL is

generated by a noncoherent filtered flashlamp with a

very broad spectrum (515–1200 nm). It can provoke

favorable microscopic effects via direct emission of a

visible polychromatic pulsed light of high intensity. IPL

has been proven to be effective for the treatment of

telengiectasias, lentigines, vascular malformations,

and leg veins and for photoepilation.24–27

It has also

shown efficacy in the treatment of poikiloderma of

Civatte and for facial photorejuvination.28,29

Based on

these results, studies were conducted using IPL to

treat striae. In a prospective study of 15 women with

abdominal striae treated with five sessions of IPL once

every 2 weeks, IPL was found to improve the clinical

and histological appearance of the striae in all 15

patients.11

Post-treatment histology showed epidermal

thickening, increases in dermal thickness, and

improvement of the quality of collagen fibers, with

reappearance of rete ridges due to the deposition of

new fibers. However, postinflammatory hyperpigmen-

tation occurred in 40% of patients, making this modality

difficult to use in dark-skinned patients.

Ultraviolet

While both the pulsed dye laser and IPL have been

used with slight success in treating striae rubra, they

have not been shown to be as effective for the treat-

ment of leukoderma in striae alba.14,19,22

In cases of

cutaneous hypopigmentation and depigmentation,

phototherapy has been shown to be of value for disor-

ders such as vitiligo, scars, and postresurfacing leuko-

derma.30–32

Recently, the narrowband 308 nm UVB

excimer laser has been used to treat striae alba. One

study treated 31 patients, who were randomized to a

treatment arm with site-matched control areas.33

Treatments were initiated with a minimal erythema

dose minus 50 mJ/cm2

to affected areas. Treatments

were performed twice a week until 50–70% pigment

correction (maximum 10 treatments). Pigment cor-

rection assessment was done by visual and colorimet-

ric assessments compared with the untreated control

lesions.The results showed a 68% increase in pigmen-

tation by visual assessment and almost a 100% increase

by colorimetric analysis after nine treatments. The

authors further noted that these results declined over

the 6-month follow-up, and recommended that main-

tenance treatment would be needed every 2–4 months

to sustain the cosmetic benefit. Goldberg et al34

exam-

ined the histological and ultrastructual changes in

UVB laser-induced repigmentation of striae alba.They

showed histological evidence of an increase in melanin

content, hypertrophy of melanocytes, and an increase

Noninvasive body rejuvenation technologies 141


in the number of dopa-positive melanocytes in all

treated lesions. They concluded that targeted UVB

phototherapy is a safe and effective temporary treat-

ment for the leukoderma in striae distensae, but that

retreatment may be required.

The results obtained with the UVB pulsed

excimer laser led to the use of a combined UVB

(304–313 nm)/UVA1 (360–370 nm) narrowband

light source (the MultiClear system) to treat striae

alba in the hope of accelerating the repigmentation

response by combining the UV wavelengths. In a study

by Sadick et al,35

10 patients with striae alba were

treated twice a week with a blend of UVB and UVA1

to the hypopigmented areas until repigmentation

occurred (maximum 20 treatments). Repigmentation

was assessed by baseline and post-therapy photogra-

phy. The authors noted that repigmentation of striae

alba occurred within one to six treatments and that

darker-skinned patients repigmented faster

(Fig. 13.1). They concluded that combined UVB/

UVA1 high-intensity light enhances the restoration of

pigment in the hypopigmented skin of striae alba.

Mid-infrared

Nonablative lasers in the mid-infrared (Mid-IR) range

have recently been examined for the treatment of

striae distensae, secondary to their studied improve-

ment in dermal remodeling and in the treatment of

facial rejuvenation and atrophic acne scars.36–38

Tay

et al39

treated 11 Asian patients with striae distensae

with the nonablative 1450 diode laser. Patients were

randomly assigned to receive 4, 8, or 12 J/cm2

with

a 6 mm spot size and a dynamic cooling device for

40 ms to protect the epidermis. A total of three treat-

ments were given at 3-week intervals and assessment


Fig.13.1 (a) Striae alba before treatment. (b) After treatment with the MultiClear combined UVB (304–313 nm)/UVA1

(360–370 nm) narrowband and light source.

a b


was done using serial photographs.The results showed

no significant improvement in any of the striae treated.

In addition, significant postinflammatory hyperpig-

mentation was noted in 64% of the patients, leading to

the conclusion that this modality is not useful for

darker skin types.

Recent new developments in nonablative laser tech-

nology have focused on fractional photothermolysis.

This produces arrays of microscopic thermal wounds

called microscopic treatment zones (MTZs) at specific

depths in the skin without injuring surrounding tissue.

There is controlled dermal heating without dermal

damage.Wounding is not apparent, because the stra-

tum corneum remains intact during treatment and acts

as a natural bandage. Downtime is minimal and ery-

thema is mild; however, multiple treatments are usu-

ally required. This new concept in skin rejuvenation

has recently been used to treat melasma, acne scars,

and photoaging.40,41

One recently published case

report looked at the treatment of surgical scars and

noted a 75% visual improvement 2 weeks after a single

treatment with the 1550 nm Fraxel SR laser.42

An

unpublished study presented at the 5th World

Congress for Cosmetic Dermatology43

treated 10

patients with striae distensae in five sessions at weekly

intervals with fractional photothermolysis. Digital

photography and patient surveys showed significant

improvement in the clinical appearance and texture of

the striae. It is likely that optimal treatment parame-

ters for striae are similar to those used to treat acne

scars and fine rhytids. Striae are further likely to

improve with multiple treatments or with a combina-

tion of other therapeutic modalities.We await further

trials looking at the treatment of striae distensae with

this new technology of fractional photothermolysis.

CELLULITE

Cellulite affects 85–98% of postpubertal females of all

races, but has a higher prevalence in Caucasians and

Asians.44,45

Although nonpathological, the unaesthetic

lipodystrophic changes that characterize cellulite have

sparked the conception of a therapeutic market geared

toward more noninvasive, patient-friendly techniques

that eliminate these unsightly fat depositions. Cellulite

describes an orange peel- or cottage cheese-type dim-

pling of the skin.46–48

The distribution of cellulite is

localized to any area of the body containing subcuta-

neous adipose tissue.There are certain target areas that

are more prone to developing cellulite, including the

hips, upper outer and posterior thighs, and buttocks.

In these areas, the local microcirculation has certain

tendencies to deposit more fat and to retain more

interstitial fluids. Cellulite can also be found on the

breasts, the lower part of the abdomen, the upper

arms, and the nape of the neck.49

Although cellulite

may be found in any area where excess adipose tissue is

deposited, obesity is not necessary for its presence.44

The dimpling of skin in cellulite is anatomically due

to herniations of fat, known as papillae adiposae, that

protrude from the subcutis through the inferior sur-

face of a weakened dermis at the dermo–hypodermal

interface.44

Various hypotheses as to how cellulite

develops have been proposed, yet the lack of a

definitive explanation only adds to the challenge of

treatment. One leading hypotheses is based on gender-

related differences in the architecture of subcutaneous

fat lobules and the connective tissue septae that divide

them.44,47,50,51

Nurnberger and Muller44

found that

women have of inherent vertical fascial bands that are

easily stretched, leading to weakening of the connec-

tive tissue foundation and making herniations mecha-

nistically more likely. In contrast, in males, the

subcutis is organized by interlocking fascial bands, cre-

ating a stronger interface through which fat is rarely

able to penetrate.49

In addition, Rosenblaum et al47

found women to have an irregular, discontinuous con-

nective tissue pattern immediately below the dermis,

but this same layer of connective tissue was both

smooth and continuous in men. The hormonal and

genetic differences in the nature of skin between gen-

ders make cellulite atypical in males who have normal

levels of androgens, regardless of their weight.52

Another hypothesis centers on the vascular changes

that accompany the formation of cellulite.50

Alterations

to the precapillary arteriolar sphincters and deposition

of hyperpolymerized glycosaminoglycans in the capil-

lary walls of the dermis initiate vessel atrophy. The

increased capillary pressure and hydrophilic tendency

of glycosaminoglycans increase capillary permeability

and cause edema. Surrounding tissues are deprived of



an adequate supply of blood, and the resulting hypoxia

increases lipolytic resistance. When combined with

an increase in lipogenesis due to estrogen, prolactin,

or high carbohydrate diets, the subcutaneous layer

becomes overwhelmed by adipocyte hypertrophy.The

enlarged fat cells, along with hypertrophy and hyper-

plasia of periadipocyte reticular fibers, form micro-

nodules surrounded by clumps of proteins. With

continued hypoxia, sclerosis of fibrose septae occurs,

leading to dimpling of the skin.52

A recent study using

MRI compared the water content of adipose tissue in

women of different ages and found a higher content of

water within the dermis of the older women. This

greater amount of water is related to collagen degra-

dation during the aging process leaves fewer interac-

tion sites between water and macromolecules, and

further promotes the formation of cellulite.53,54

Currently, there is no definitive treatment for cel-

lulite, although a variety of treatments have been

directed at these hypotheses of the pathophysiology of

its development.These include topical, surgical, laser

and mesotherapy.These treatments try to enhance the

esthetic appearance of skin by improving tone and

superficial tightening while promoting lymphatic

drainage of fats.We will discuss the data on noninva-

sive lasers for the treatment for cellulite.

Velasmooth

Two laser light devices at present have received

approval from the US Food and Drug Administration

(FDA) for the safe and effective treatment of cellulite.

One system, Velasmooth (Syneron Medical Ltd) uti-

lizes a unique integration of bipolar radiofrequency

(RF), 700 nm wavelength IR, and negative tissue mas-

sage to noninvasively treat cellulite. Twice-weekly

treatment for a total of 8–10 sessions has been recom-

mended. A synergistic effect is employed between

the two forms of energy when the various optical

and bipolar RF parameters are set optimally.55

Additionally, lower energy levels can also be used to

potentially reduce side-effects associated with either

the IR or RF alone, making this treatment available to

a variety of skin types. It has been proposed that

improved microcirculation is effected by the vasodila-

tory effect and enhanced lymphatic drainage of the

mechanical massage, while neocollagenesis, collagen

contraction, and controlled tissue inflammation are

induced by heating of tissue by RF and IR.56

Shaoul57

conducted a study treating 15 female patients with cel-

lulite with combined optical and IR energy sources

and showed improved appearance of cellulite in all

patients by an average of 65%. Additionally, hip para-

meters were reduced by an average of 3.2 cm, and all

patients reported feeling skin contraction as a result of

the treatment. No complications were noted either

during or after the treatment, thereby showing the

success of the VelaSmooth system in delivering a suffi-

cient quantity of deep heat without any superficial

damage. Another study, conducted by Alster et al,56

involved 20 patients of varying skin phototypes (I–V)

who underwent eight 30-minute sessions of the

VelaSmooth device delivered to the randomly selected

upper anteromedial and posteolateral thigh and but-

tock twice a week over a 1-month period, using the

contralateral side as a nontreated comparative control.

Circumferential thigh measurements were reduced by

0.8 cm on the treatment side, with mean clinical

improvement scores of 50%. Side-effects were limited

to transient erythema, lasting less than an hour, in

most patients upon initial treatment. In another two-

center study involving 35 females (mean age 43) with

cellulite abnormalities of the thighs and/or buttocks,

8–16 VelaSmooth treatments were administered

biweekly.58

The treatment had positive results, includ-

ing a moderate improvement in skin smoothing and

cellulite appearance and an overall mean decrease in

thigh circumference of 0.8 inches (Fig. 13.2). Punch

biopsies were taken at baseline, after two treatments,

and after eight treatments of the lateral thighs in order

to evaluate the histological changes at the molecular

level. Histological assessment showed no evidence of

morphological damage to any of the skin structures,

either epithelial or mesenchymal. This analysis indi-

cates that VelaSmooth, used at specified energy levels,

does not result in any significant skin damage.

Therefore, any clinically evident changes are probably

associated with deeply located alterations, in either the

subcutaneous tissue or the subfascial structures. In

terms of safety, a few patients reported minimal dis-

comfort and temporary swelling, while two patients

reported crusting that resolved in less than 72 hours.

These occurrences were attributed to improper



vacuum contact and coupling of electrodes. These

studies demonstrate that the VelaSmooth system can

have beneficial effects on the appearance of cellulite, as

the negative-pressure massage serves to improve cir-

culation and loosen bands of connective tissue around

the fat deposits that cause fat dimpling, while the RF

and IR energies heat the skin, creating a controlled

inflammatory response that renders fat more malleable

to the rolling action of the massage unit. Lymphatic

drainage is thus enhanced, thereby reducing tissue

bulk and dimpling. The synergistic effects of RF, IR,

and suction-based massage are safe and effective, and

maintenance treatments may be used to extend the

esthetic results obtained.52,56–58

TriActive

The other FDA-approved system is the TriActive

LaserDermology System (Cynosure, Inc.).This system

works to eliminate the appearance of cellulite by com-

bining three different modalities. An 810 nm diode

laser promotes arterial, venous, and lymphatic

drainage in conjunction with a localized cooling sys-

tem that reduces edema. Lastly, a rhythmic massage

works in various directions in order to reactivate the

collagenic and elastic toning while stimulating lym-

phatic drainage. A study by Zerbinati et al59

employed

the TriActive device on 10 patients with localized

cellulite. The sessions lasted 30 minutes and were

conducted three times a week. The results showed a

marked reduction in circumference of the treated hips

and thighs, as well as clinical evidence of increased skin

elasticity. Boyce et al60

conducted a study on 16 female

patients with cellulite on the thighs or hips and

an average starting body fat percentage of 22.18%.

After 12 treatments, all subjects had reported some

improvement in the appearance of cellulite, skin tone,

and texture. Blinded investigators found an average

improvement of 23% for the appearance of the cel-

lulite upon evaluation of photographs. Additionally,

no long-term adverse complications such as scarring,

dyspigmentation, or cellulite worsening were reported

during the use of the TriActive system.

Monopolar radiofrequency

The most recent cellulite treatment uses unipolar RF

energy and is known as the Accent RF System (Alma

Lasers, Inc). The selective electrothermolysis pro-

duced by RF is highly effective in creating a thermal

effect on tissues. Unlike optical energy, which depends

on the chromophore concentration of the skin in order

to achieve a selective thermal destruction of target

tissue, RF depends on the electrical properties of the

tissues.61

The Accent system consists of a base system

that generates RF energy (at 40.68 MHz), which is

delivered through one of two handpiece applicators to

induce controlled volumetric tissue heating.The indi-

vidual applicators provide a functional delivery of

energy to different depths.The first handpiece delivers

bipolar energy and has a penetration between 2 and

6 mm to stimulate dermal structural changes. This


Fig.13.2 (a) Cellulite before treatment. (b) 8 weeks after treatment with the Velasmooth combined radiofrequency, infrared,

and negative tissue massage device.

a b


bipolar handpiece promotes local dermal heating and a

subsequent contraction of collagen tissue.The second

handpiece delivers unipolar energy with a penetration

of 20 mm and is designed to reach subcutaneous adi-

pose tissue.The unipolar device induces thermal injury

and inflammation, which promotes collagen remodel-

ing while simultaneously enhancing local microcircu-

lation and fatty acid dissolution to the lymphatic

system.62

Emilia del Pino et al54

conducted RF treat-

ments on 26 women between the ages of 18 and 50

while using real-time scanning-image ultrasound with

a multifrequency linear transducer to evaluate the

thickness of subcutaneous tissue on the buttocks and

thighs.The treatments were delivered in two sessions,

15 days apart, and the ultrasound evaluations were

made at baseline and 15 days after the final treatment.

Dermal thickness was measured as the average of the

two distances between the dermal–epidermal union

up to the limit of Camper’s fascia, superficial and deep.

In the thigh, the shortening of this distance was over

70%, with an average reduction of 2.64 mm. In the

buttocks, measurements of the thickness of the dermis

to Camper’s fascia demonstrated a reduction of 64%,

with an average shortening of 1.8 mm. Additionally,

analysis of the echogenicity changes in Camper’s fascia

between the first session and 45 days later showed a

noticeable organization of the fibrous lines as well as

an increase of fibrous tissue in 53% of cases, accompa-

nied by an increase of thickness of the fibers in 57% of

cases. Adverse effects were reported during the treat-

ment, and included small blisters in two of the patients

as well as ecchymosis on the thighs of three of the

patients 24 hours post treatment.While this prelimi-

nary study seems promising, more clinical studies are

needed to evaluate the use of unipolar RF for the treat-

ment of cellulite.

Currently, there is no perfect treatment of cellulite.

Part of the problem is the lack of complete under-

standing of its etiology.There are many opportunities

for further investigation into both the pathophysiology

and the noninvasive treatment of cellulite.

LIPOLYSIS

Similar to laser treatment for cellulite, several lasers

have been developed to decrease adipose tissue.

Adipose tissue is a complex endocrine organ com-

prised primarily of fat cells surrounded by a frame-

work of protein fibers and ground substance. Each

adipocyte is composed of a plasma membrane contain-

ing a flat nucleus, a small amount of cytoplasm, and

typically one large triglyceride droplet. The triglyc-

eride molecule is hydrolyzed via lipolysis to glycerol

and free fatty acids. The released fatty acids may

undergo further breakdown, be re-esterified, or move

into the blood to fuel other organs. Lipolysis is a

complex process that is dependent on the hormone-

sensitive lipase, an enzyme that is tightly regulated by

physical activity, age, pathological conditions, and

dietary state. Chronic overfeeding, the most powerful

cause of obesity, can stimulate adipocytes to differenti-

ate into precursor cells and increase the size of fat cells

at certain localized subcutaneous adipose tissue sites.63

Attempts to reduce localized adiposity by diet or

exercise alone are often unsuccessful. Over the years, a

variety of surgical and medical interventions have been

used to remove subcutaneous fat in order to reduce

downtime, operator effort, and bleeding, as well as to

achieve tightening, fine sculpture, and treatment of

fibrous, reoperative areas.64

The use of lasers in the

removal of unwanted fat was introduced in 1992.65

Laser lipolysis offers excellent patient tolerance and

rapid recovery, as well as the benefit of dermal tighten-

ing. It can be used alone for small focal areas or it poten-

tially can be combined with liposuction as an adjunct to

reduce operator effort and to enhance skin retraction.

Laser lipolysis is associated with rapid recovery due to

minimal mechanical disruption. It is a minimally inva-

sive option for people who want to avoid more aggres-

sive procedures such as necklifts. It may also be helpful

in areas that are not suitable for liposuction or in focal

areas that have already undergone liposuction and

require additional sculpting.65

Laser lipolysis is a precise,

delicate method that has the advantage of the thermal

laser effect, which can be used for refinement in very

small areas, including the face.66

The variety of nonabla-

tive techniques currently being employed, each of

which manipulates different laser frequencies to mecha-

nistically target fat, allows for an individualization of the

treatment regimen according to the patient’s aesthetic

wishes.

The mechanism of action of laser lipolysis is selec-

tive photohyperthermia.67

In this process, laser light



energy is converted into heat energy when absorbed

by fat. Conducted by a flexible fiberoptic delivered

through a cannula, the laser energy is transmitted to

the adipocytes, which absorb it, expand, and rupture.

A photoacoustic effect may also play a role in cellular

lysis, due to the rapid absorption of laser light by the

cell and the consequent heating.The action time of the

laser varies according to the area to be treated and

the tissue resistance. In areas of fibrosis or previously

treated zones, the treatment time is typically longer.

All subjects suitable for the traditional liposuction

method can also be treated with laser lipolysis.67

Nd:YAG laser lipolysis

Laser lipolysis with the pulsed neodymium : yttrium

aluminum garnet (Nd:YAG) laser has shown very

promising results. Badin et al66

performed Nd:YAG

lipolysis using the higher-energy 1064 nm laser on 245

patients with focal areas of moderate flaccidity, after

which aspiration of the liquid fat allowed for histologi-

cal analysis. The area created with the laser received

irreversible damage (cytoplasmic retraction and dis-

ruption of membranes) and a decrease in diameter of

each adipocyte as seen histologically.66,68

The interac-

tion of the laser with the collagenous and subdermal

bands also showed histological evidence of melting and

rupture – a process that liberated the retracted skin

and remodeled the collagenous tissue. Along with the

original theories proposed in 1992, the authors fur-

ther concluded that the results showed that the laser–

tissue interaction causes thermal damage the cellular

membrane of the adipocyte through the liberation of

heat and alteration of the sodium–potassium pump.

This alteration of sodium–potassium cell homeostasis

permits migration of water into the cells, forcing them

to rupture.69–70

Clinically, the tissue interaction pro-

duced minimal swelling and yielded good contour

results. Recently, Goldman67

studied 82 patients who

underwent submental laser lipolysis for neck lipodys-

trophy using the Nd:YAG laser, with the main parame-

ter of assessment being histological studies of tissues

removed from the subjects immediately following the

procedure and of biopsies taken approximately 40 days

post treatment. Significant findings following the pro-

cedure included coagulation of small blood vessels in

the fatty tissue, rupture of adipocytes, the appearance

of small channels produced by laser action, reorganiza-

tion of the reticular dermis, and coagulation of colla-

gen in the fat tissue. These factors were thought to

be responsible for the observed tissue retraction

observed following the procedure. Ichikawa et al71

reported on the histological evaluation of subcuta-

neous tissue treated first with the pulsed Nd:YAG

laser as an adjunct to lipoplasty. Scanning electron

microscopy of the removed tissue showed a greater

destruction of adipocytes than in the nontreated con-

trol tissue. In addition, degenerated cell membrane,

vaporization, liquefaction, and thermally coagulated

collagen fibers were observed. Kim and Geronemus65

conducted a study using the 1064 Nd:YAG laser to

evaluate safety and efficacy in the treatment of small

areas of unwanted fat.Thirty female subjects were ran-

domly assigned to three treatment groups: 10 subjects

underwent 1064 nm Nd:YAG laser lipolysis, 10 sub-

jects underwent laser lipolysis followed by biweekly

treatment with the TriActive diode laser with contact

cooling and suction, and 10 subjects served as the con-

trol group. Assessment was done at baseline, 1 week,

1 month, and 3 months post procedure using clinical

evaluation, weight, photographs, and subject question-

naires, as well as magnetic resonance imaging (MRI)

evaluation for the laser lipolysis-only group. Self-

assessment evaluations reported an average individual

improvement of 37% at the 3-month follow-up.Those

who underwent the TriActive treatments reported a

higher subjective improvement of 47% compared with

those who were treated with the 1064 nm Nd:YAG

laser alone (33%), suggesting a beneficial role of the

combined modality. MRI obtained pre procedure and

3 months post procedure of the 1064 nm Nd:YAG-

treated group showed an average 17% reduction in fat

volume of the treated areas, with the submentum hav-

ing the greatest reduction compared with other larger

treatment sites. This, in turn, may suggest a dose-

dependent relationship.

Ultrasound

A novel device for noninvasive destruction of fat

cells by focused ultrasound has been developed by

UltraShape System Ltd (TelAviv, Israel) and is cur-

rently undergoing clinical trials. This technique pro-

duces selective fat lysis by breaking the adipocyte



membranes, with no damage to neighboring structures

such as skin, blood vessels, and peripheral nerves.

It is proposed that triglycerides from the broken

adipocytes are released into interstitial fluid, where

they are transported by the lymphatics to the liver and

metabolized.72,73

In multicenter clinical trials for CE

approval in Europe, 165 patients were followed for 3

months following a single treatment to the abdomen,

flanks, or external thighs.74

Blood analysis, weight,

and circumference measurements were recorded.

Circumference reduction following a single treatment

averaged more than 2 cm, and all blood levels remained

within the normal range. Another preliminary study

involved 34 healthy volunteers who were treated with

the UltraShape system to either the abdomen, external

thighs, or flanks for up to 2 hours.72

Reduction in cir-

cumference of all three treated areas was observed

in all patients, as well as a pronounced reduction in

the average fat thickness, as measured by ultrasonic

imaging.

LipoSonix, Inc. have developed another variant on

ultrasound technology that achieves targeted reduction

of tissue volume by precisely concentrating high-

intensity focused ultrasound (HIFU) energy on adipose

tissue.The ultrasound transducer is delivered across the

skin surface at a relatively low intensity but brings this

energy to a sharp focus in the subcutaneous fat. At the

skin surface, the intensity of the ultrasound energy is

low enough that no damage occurs. In a recent animal

model, transcutaneous HIFU was administered at the

sites of thermocouples anatomically placed at the epi-

dermis, dermis, and subcutaneous adipose tissue of

swine at depths of 10 and 15 mm, and within the

intraabdominal cavity.75

Temperature data showed a

steep temperature gradient between the HIFU-treated

tissue and the adjacent tissue that was not within the

HIFU treatment beam. The thermal and mechanical

effects of the ultrasound within the targeted tissue were

shown to induce cell death through focused thermal

coagulation without damaging intervening or underly-

ing structures. In a clinical trial, 24 patients underwent

HIFU to their lower abdominal tissue followed by

abdominoplasty.76

Eight-week histology revealed 75%

resolution of the treated adipose tissue, with collapse of

the surrounding fibrovascular stroma.This study pro-

vided a histopathological examination of the effect of

HIFU on adipose tissue.

Low-level Laser

Recently, low-level laser lipoplasty has been increas-

ingly used as an effective lipolysis treatment for a

broad range of conditions, showing results such as

improved wound healing, reduced edema, and relief of

pain. Neira et al77

stated that 99% of fat was released

from adipocytes after 6 minutes of 635 nm, 10 mW

diode laser exposures in a study involving patients

treated with low-level laser-assisted lipoplasty. Total

energy values of 1.2 J/cm2, 2.4 J/cm

2, and 3.6 J/cm

2

were applied to human adipose tissue taken from

lipectomy samples of 12 healthy women.The samples

were irradiated for 0, 2, 4, and 6 minutes and were

analyzed using both scanning and transmission elec-

tron microscopy. Histological results showed that after

just 4 minutes of laser exposure, 80% of the fat was

released and collected in the interstitial space. The

low-level laser works by opening a transitory pore in

the cell membrane, allowing the fat content to seep

out of the cell.77–79

Laser lipolysis is a relatively new technique, and is

still under development and in need of further clinical

trials.The main objectives are rapid recovery and skin

tightening. Basic and clinical research is needed on the

laser effect of catabolic activation, softening, and

liquefying fat.

SKIN TIGHTENING

Redundant body skin laxity is a major feature of aging.

Rejuvenation of loose skin has become an increasingly

popular practice as a result of the maturing ‘baby

boomer’ population concomitant with a greater

societal acceptance of cosmetic procedures. Although

dramatic clinical improvement can be achieved with

surgical lifting procedures, patients may be hesitant to

pursue this treatment option because of the extensive

postoperative recovery period and the inherent risks

of the procedure. Nonablative modalities obviate the

need for epidermal injury and promote both reorgani-

zation and increase of important dermal structures to

potentially reverse aging of the skin.80,81

Aging skin

manifests as rhytids, pigmentary changes, skin coarse-

ness, and roughness with diminished elasticity. The

skin displays characteristic alterations in dermal



connective tissue, evidenced histologically by disorga-

nized collagen fibrils and abnormal elastic mater-

ial.82–85

Repeated sun exposure is accompanied by

elevations in matrix metalloproteinases and collagen

degradation, and may lead to persistent breakdown of

dermal elements.These alterations in collagen organi-

zation contribute to the skin laxity and wrinkling seen

in aging and photodamaged skin.82

Long-term studies examining the histological

changes after CO2

and erbium laser resurfacing have

been predominantly confined to the dermis, with

extensive collagen and elastic fiber reorganization.86–88

The significance of these microscopic findings lies in

their correlation with clinical improvement of rhytids,

suggesting that dermal remodeling rather than

epidermal ablation is largely responsible for wrinkle

reduction and that epidermal removal may not be nec-

essary.89

Only a deep penetrating method of heating

the dermis and possibly the fibrous septae supporting

the dermis and subcutaneous fat to the underlying fas-

cia could possibly have the effect of tightening and

contouring nonsurgically mild to moderate laxity of

the skin.81

On the basis of these results, it is believed

that promoting dermal collagen remodeling with

nonablative laser treatments can improve the clinical

manifestations of photoaging, including rhytids,

texture, and tone.89

Although much remains to be elucidated about the

precise mechanism of action of nonablative tech-

niques, important factors have been extrapolated from

existing studies. Spatially selective photocoagulation is

a term used to refer to the process of epidermal spar-

ing and selective thermal injury to the dermis, and

most precisely describes nonablative laser techniques.

Key components to nonablative rejuvenation are epi-

dermal sparing and proper selection of laser irradia-

tion wavelength and energy to evoke the desired

thermal response in the papillary and upper reticular

dermis.89

The depth of thermal injury should be

limited to 100–400 µm below the epidermis – the

area where solar elastosis is seen histologically.87,88

Epidermal protection can be accomplished by cryogen

spray or contact cooling. By cooling the skin, thermal

injury can be confined to the papillary and upper retic-

ular dermis. One should avoid heating the epidermis

to temperatures above 65ºC, as this is the threshold for

epidermal denaturation.90

Heating the dermis causes

collagen denaturation and fibroblast stimulation via an

inflammatory cascade leading to neocollagenesis.91

Nonablative rejuvenation has great applicability in

the treatment of darker skin types, making it an attrac-

tive option for individuals with atrophic scars or those

who want to improve their skin texture and tone but

are not candidates for skin resurfacing procedures due

to the increased risk of pigmentary alterations. The

ease and tolerability of the treatments, the lack of

downtime, and the low risk of epidermal injury make

nonablative treatments a mainstay of therapy for all

skin types.89

Radiofrequency

RF energy is electromagnetic radiation with frequen-

cies ranging from 3kHz to 300 GHz. Delivery of RF

energy to living tissue is thought to induce dermal

heating to the critical temperature of 65ºC, causing

collagen to denature and allowing wound healing with

subsequent contraction.89

As exemplified by the

ThermaCool TC system, RF energy is distributed over

a volume of tissue though a thin capacitive membrane,

while a cryogen system simultaneously cools the epi-

dermis for protection. Tissue heat is generated based

on the tissue’s natural resistance to movement of ions

within an RF field. This unique volumetric heating

method allows large amounts of energy to be distrib-

uted over a three-dimensional volume of dermal tissue

while protecting the epidermis.81

Unlike lasers, RF

sources are not limited by the disadvantages of optical

energy, in that they do not rely on the strong inter-

dependence between treatment efficacy/safety and

chromophore levels within the epidermis.92

The high

efficiency of RF current for tissue heating makes it an

attractive energy source for various dermatological

applications, including skin tightening, hair and leg

vein removal, treatment of acne scarring, skin rejuve-

nation, and wrinkle reduction. RF is similar to optical

energy in that it interacts with the tissue to produce

thermal changes. In contrast, however, RF energy is

conducted electrically to tissues, and heat arises from a

current of ions rather than absorption of photons.93

While a variety of studies have documented the effi-

cacy of RF skin rejuvenation on periorbital rhytids,

nasolabial folds, eyebrow elevation, and cheek laxity,93

there is a growing use of RF to treat skin laxity on the



body (Fig. 13.3).A pilot study reported the histological

and ultrastructural effects of various settings of RF on

in vivo human skin using abdominal skin from two

women undergoing abdominoplasty using RF treat-

ment before excision.94

Electron microscopy results

taken from the human skin showed a loss of distinct

borders of collagen fibrils and an increase in size, with

no change being observed in the control group. On

Northern blot analysis, treated skin had higher levels

of collagen messenger RNA on days 2 and 7 post treat-

ment, which is highly suggestive of increased collagen

gene expression. Kist et al95

investigated whether

more advanced collagen changes would occur with

multiple passes of the Thermacool device on the peri-

auricular area of three subjects. Biopsies taken at 24

hours and at 6 months post treatment showed that RF

treatment resulted in collagen contraction. The

response to injury is the production of new collagen,

which in turn decreases skin laxity. Electron

microscopy revealed that collagen fibrils increased in

diameter proportionally to the number of passes of RF

conducted on the patient.Additionally, increases in the

energy setting also increased the occurrence of irre-

versible collagen fibril damage; however, this was asso-

ciated with increased pain. Alster et al96

studied 50

patients of varying skin phototypes with mild to

moderate cheek or neck laxity in a study employing

nonablative RF treatment delivered in a single,

nonoverlapping pass. Significant improvements in

cheek and neck skin laxity were observed in the

majority of patients, with patient satisfaction scores

paralleling the clinical improvements observed. Side-

effects were mild and limited to transient erythema,

edema, and rare dysesthesia, and no scarring or pig-

mentary alteration was seen. Applying the results of

RF to improve facial laxity, studies are currently being

conducted using it for body rejuvenation.

Another device, the Polaris WR (Syneron Medical,

Ltd) is a combination of RF and a 900 nm diode laser.

It delivers optical energy to preheat the target and RF

energy to heat it. The Polaris has shown efficacy and

safety in the treatment of facial rhytids, skin laxity, and

skin texture.97,98

Nd:YAG laser

The 1320 nm Nd:YAG laser system was specifically

designed for nonablative resurfacing as it has both a

thermal sensing device and a built-in cryogen cooling

system. This laser mechanistically injures the dermis

while protecting the epidermis with its skin cooling


Fig.13.3 (a) Before treatment. (b) After treatment with the Thermage radiofrequency device.

a b


mechanism. By cooling the dermis, the epidermal

chromophores are effectively shielded by the incident

light.99

The long-pulse Nd:YAG laser emits energy in

the IR region of the spectrum (at 1064 nm), with

extended pulse durations. This wavelength achieves

excellent penetration into the papillary and midreticu-

lar dermis, where it is nonspecifically absorbed by der-

mal water.99–101

The large scattering coefficient of the

1320 nm Nd:YAG laser causes the thermal energy to

disperse laterally within the dermis, inducing a large

volume of dermal injury relative to the beam size.102

Diffuse heating of dermal tissue at this wavelength

penetrates to depths of 5–10 mm and permits

slow heat diffusion with low energy absorption by

melanin.89

Sadick et al102

conducted a study of seven

subjects treated with the 1320 nm Nd:YAG laser to the

posterior aspects of the hands.They had six laser treat-

ments performed during a 1-month interval. Each

treatment consisted of two consecutive passes of the

laser beam, with each pass being delivered to the

entire dorsal surface of the hand in uniform nonover-

lapping pulses. Evaluation of improvement was based

on increased smoothness of the skin. Improvement

was measured by both objective and patient assess-

ments. Significant improvement was reported by six of

the seven patients at the 6-month visit. A study com-

paring the effectiveness of a single treatment of RF

versus a single treatment of long-pulse Nd:YAG laser

for skin laxity of the face and neck found equal or

moderately better results in the cohort receiving the

long-pulse Nd:YAG laser treatment.103

A study com-

paring the long-pulse 532 nm potassium titanyl phos-

phate (KTP) laser with the 1064 nm Nd:YAG laser

alone or in combination has been reported.104

A total

of 150 patients with varying skin types were treated

in three groups: 50 patients were treated with the

532 nm laser alone, 50 patients were treated with the

1064 nm laser alone, and 50 patients were treated with

both lasers together. Clinical parameters of investiga-

tor, subject, and observer assessment were conducted

after three and six treatments, and included redness,

pigmentation, tone/tightening, texture, and rhytids.

Although statistically significant improvements were

found in all categories in all three groups, the KTP and

Nd:YAG laser in combination yielded greater results

than either used alone, and the KTP laser was found to

be superior to the Nd:YAG laser alone. Serial skin

biopsies taken from the inner upper arms of four ran-

dom patients showed that the amounts of collagen and

elastin more than doubled after six treatments with

the KTP and Nd:YAG laser combined.The energy was

shown histologically to be absorbed in different areas

within the dermal papillae and dermis, with the KTP

laser mainly targeting more superficial and smaller

vessels and the Nd:YAG laser being absorbed in deeper

layers.


Fig.13.4 (a) Before treatment. (b) After treatment with the Titan infrared device.

a b



Fig.13.5 (a,b) Before treatment. (c,d) After treatment with the ReFirme combined infrared and radiofrequency device.

a b

c d

Infrared

IR light can also be used as an alternative source of

energy for the purpose of skin tightening. A non-

coherent, selectively filtered IR device, such as the

Titan system, emits IR light in multisecond cycles

and has been developed with the intention to provide

dermal heating. Water, as the target chromophore,

allows for uniform heating of the targeted reticular

dermis. The epidermis is protected by contact cool-

ing (Fig. 13.4).81

Another system, ReFirme, combines pulses of IR

light (700–2000 nm) simultaneously with bipolar RF,

which intersect to provide controlled thermal energy.

The bipolar electrodes deliver an RF current inside the

tissue along the route of lowest impedance between

the electrodes.93

Sleightholm et al105

evaluated the

ReFirme device on 31 patients with skin laxity of

the face, neck, and abdomen. Skin laxity clearance

rates were found to be highly correlated with patient

satisfaction levels.When compared to previous studies

done on the 900 nm Polaris device, the ReFirme

device was shown to provide similar outcomes, possi-

bly due to the broader IR spectrum (Fig. 13.5).

CONCLUSIONS

Noninvasive body rejuvenation is in its infancy. As the

aging population continues to look for rejuvenation

procedures that deliver achievable results yet with

reduced downtime and minimal risk profile, this field

will continue to emerge. Several systems have been

shown to effect striae distensae, cellulite, lipolysis, and

skin tightening. However, no system has emerged as

being clearly superior. With increasing technological

advances and increases in clinical data and scientific

studies, the techniques of noninvasive body rejuvena-

tion will continue to be a popular choice for patients

seeking treatment.


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Paper.pdf


INTRODUCTION

Lasers and intense pulsed light (IPL) are used to treat leg

telangiectasia for various reasons. First, both treatments

have a futuristic appeal not only to the general public but

also to physicians. By virtue of their advanced technology,

they are perceived as ‘state-of-the-art’ treatment modali-

ties and are sought by the general public because ‘high

tech’ is thought of as safer and better than traditional scle-

rotherapy. Unfortunately, these perceptions have often

resulted in unanticipated adverse sequelae (scarring and

pain) at an increased cost to the patient (lasers costing

considerably more to purchase and maintain than a

needle, syringe, and sclerosing solution).

Second, lasers may have theoretical advantages com-

pared with sclerotherapy for treating leg telangiecta-

sia. Sclerotherapy-induced pigmentation is caused by

hemosiderin deposition through extravasated erythro-

cytes. Laser coagulation of vessels should not have this

effect. Telangiectatic matting (TM) has also not been

associated with laser treatment of any vascular condi-

tion and occurs in a significant percent of sclerother-

apy-treated patients. Finally, allergenic reactions that

may rarely occur from the sclerosing solution do not

occur with laser treatment.

Both lasers and IPL act in a different manner to

effect vessel destruction. Effective lasers and IPL

are pulsed so that they act within the thermal relax-

ation times of blood vessels to produce specific

destruction of vessels of various diameters based on

the pulse duration. Lasers of various wavelengths and

broadspectrum IPL are used to selectively treat blood

vessels by taking advantage of the difference between

the absorption of the components in a blood vessel

(oxygenated, deoxygenated, and met-hemoglobin)

and the overlying epidermis and surrounding dermis

(as described below) to selectively thermocoagulate

blood vessels. In addition, each wavelength requires a

specific fluence to cause vessel destruction.

Unlike the oxygenated blood of port wine stains

(PWS) and hemangiomas, leg veins harbor deoxy-

genated hemoglobin, which gives the blue color of

venous blood. Deoxyhemoglobin has distinct optical

properties, with two absorption spectrum peaks at

approximately 545 and 580 nm, and a broader peak at

about 650 nm.

The optical properties of blood are mainly deter-

mined by the absorption and scattering coefficients of

its various oxyhemoglobin components. Figure 14.1

shows the oxyhemoglobin absorption and scattering

coefficient for penetration into blood.1The main feature

to note in the curve is the strong absorption at wave-

lengths below 600 nm, with less absorption at longer

wavelengths. However, a vessel 1 mm in diameter

absorbs more than 67% of light even at wavelengths

longer than 600 nm.This absorption is even more signif-

icant for blood vessels 2 mm in diameter.Therefore the

use of a light source above 600 nm would result in

deeper penetration of thermal energy without negating

absorption by oxyhemoglobin in vessels greater than

1 mm in diameter.This is because the absorption coeffi-

cient in blood is higher than that of surrounding tissue

14. Treatment of leg telangiectasia with

laser and pulsed light*

Mitchel P Goldman

*Portions of this chapter are excerpted from Goldman MP, Bergan JB, Guex JJ, eds. Sclerotherapy Treatment of Varicose and Telangiectatic Leg Veins,

4th edn. London: Elsevier, 2006.


for wavelengths between 600 and 1064 nm. Ideally, a

light source should have a pulse duration that would

allow the light energy to build up in the target vessel so

that its entire diameter is thermocoagulated. Optimal

pulse durations have been calculated for blood vessels of

various diameter (Table 14.1).

During the process of delivering a sufficient

amount of energy to thermocoagulate the target ves-

sel, the overlying epidermis and perivascular tissue

should be unharmed. This selective preservation of

tissue requires some form of epidermal cooling. A

number of different laser and IPL systems have been

developed toward this end, and are discussed in subse-

quent sections.

Patients seek treatment for leg veins mostly for cos-

metic reasons, and any treatment that is effective

should be relatively free of adverse sequelae.2Bernstein,

3

for example, evaluated the clinical characteristics of

500 consecutive patients presenting for removal of


532 Nd:YAG

Nd:YAGPDL

WaterAb

sorp

tio

n (

log

sca

le)

300 500 700 1000

Wavelength (nm)

2000

Diode

Melanin

Oxyhemoglobin

Fig.14.1 Oxygenated and deoxygenated hemoglobin.Water and melanin absorption curves as a function of wavelength.

(Adapted from Boulnois JL.Lasers Med Sci 1986;and reproduced with permission from Sclerotherapy Treatment of Varicose and

Telangiectatic Leg Veins,4th edn.Goldman MP,Bergan JB,Guex JJ, eds.Elsevier,London,2006.)

Table 14.1 Thermal relaxation times of blood vessels

Vessel diameter (mm) Relaxation time (s)

0.1 0.01

0.2 0.04

0.4 0.16

0.8 0.6

2.0 4.0


lower extremity spider veins. Patients ranged in age

from 20 to 70 years and had had noticeable spider

veins for an average of 14 years; 28% had leg veins less

than 0.5 mm in diameter and 39% veins less than

1.5 mm in diameter. Interestingly, regardless of

exactly how sclerotherapy was performed, more than

half (56%) of patients developed TM. Recent advances

in laser and IPL treatments for treating telangiectatic

vessels, if used appropriately, assure minimal (if any)

adverse events.

An understanding of the appropriate target vessel

for each laser and/or IPL is important so that treat-

ment is tailored to the appropriate target. As detailed

in sclerotherapy textbooks and articles,4

most telang-

iectasias arise from reticular veins.Therefore the single

most important concept to keep in mind is that feed-

ing reticular veins must be treated completely before

treating telangiectasia. This minimizes adverse seque-

lae and enhances therapeutic results. Failure to treat

‘feeding’ reticular veins and short follow-up periods

after the use of lasers may give inflated estimates of the

success of laser treatment.5This chapter reviews and

evaluates the use of these nonspecific and specific laser

and light systems in the treatment of leg venules and

telangiectasias (Table 14.2).

HISTOLOGY OF LEG

TELANGIECTASIA

The choice of proper wavelength(s), degree of energy

fluence, and pulse duration of light exposure are all

related to the type and size of target vessel treated.

Deeper vessels necessitate a longer wavelength to

allow penetration. Large-diameter vessels necessitate a

longer pulse duration to effectively thermocoagulate

the entire vessel wall, allowing sufficient time for

thermal energy to diffuse evenly throughout the vessel

lumen.The correct choice of treatment parameters is

aided by an understanding of the histology of the

target telangiectasia.

Venules in the upper and middle dermis typically

maintain a horizontal orientation.The diameter of the

postcapillary venule ranges from 12 to 35 µm.6

Collecting venules range from 40 to 60 µm in the

upper and middle dermis and enlarge to 100–400 µm

in diameter in the deeper tissues. Histological

examination of simple telangiectasia demonstrates

dilated blood channels in a normal dermal stroma,

with a single endothelial cell lining, limited muscu-

laris, and adventitial layers.7,8

Most leg telangiectasias

measure from 26 to 225 µm in diameter. Electron

microscopic examination of ‘sunburst’ varicosities

of the leg has demonstrated that these vessels are

widened cutaneous veins.They are found 175–382 µm

below the stratum granulosum. The thickened vessel

walls are composed of endothelial cells covered with

collagen, elastic, and muscle fibers.

Unlike leg telangiectasias, the ectatic vessels of PWS

are arranged in a loose fashion throughout the super-

ficial and deep dermis. They are more superficial

(0.46 mm) and much smaller than leg telangiectasias,

usually measuring 10–40 µm in diameter. This may

explain the lack of efficacy reported by many physi-

cians who treat leg telangiectasias with the same laser

and parameters as they do with PWS.

KTP AND FREQUENCY-DOUBLED

Nd-YAG (532 nm) LASERS

Modulated potassium titanyl phosphate (KTP) lasers

have been reported to be effective at removing leg

telangiectasia, using pulse durations between 1 and

50 ms. The 532 nm wavelength is one of the hemo-

globin absorption peaks. Although this wavelength

does not penetrate deeply into the dermis (about

0.75 mm), relatively specific damage (compared with

argon laser) can occur in the vascular target by selec-

tion of an optimal pulse duration, enlargement of

spot size, and addition of epidermal cooling.

Effective results have been achieved by tracing ves-

sels with a 1mm projected spot.Typically, the laser is

moved between adjacent 1 mm spots, with vessels

traced at 5–10 mm/s. Immediately after laser expo-

sure, the epidermis is blanched. Lengthening of the

pulse duration to match the diameter of the vessel is

attempted to optimize treatment.

We and others have found the long-pulse 532 nm

laser (frequency-doubled neodymium : yttrium alu-

minum garnet (Nd:YAG)) to be effective in treating

leg veins less than 1 mm in diameter that are not

directly connected to a feeding reticular vein.9When

used with a 4°C chilled tip, a fluence of 12–15 J/cm2

is

Treatment of leg telangiectasia with laser and pulsed light 159



Table 14.2 Lasers and light sources for leg veins

Pulse Spot

Product Device Wavelength Energy duration diameter

Supplier name typea

(nm) (J) (ms) (mm) Coolingb

American OmniLight Fluorescent 480, 515, 535, Up to 90 Up to 500 External

BioCare FPL IPL 550, 580–1200 continuous

Adept Medical Ultrawave Nd:YAG 1064 5–500 5–00 2, 4, 6, 8, 10, 12 None

Alderm Prolite IPL 550–900 10–50 10 × 20, 20 × 25

Asclepion- Pro Yellow CuBr 578 55 300 1.5 None

Meditech

Candela Vbeam PDL 595 25 0.45–40 5, 7, 10, 12 DCD

Cbeam PDL 585 8–16 0.45 5, 7, 10 DCD

Gentle YAG Nd:YAG 1064 Up to 600 0.25–300 DCD

CoolTouch Varia Nd:YAG 1064 Up to 500 300–500 3–10 DCD

Cutera Vantage Nd:YAG 1064 Up to 300 0.1–300 3, 5, 7, 10 Copper

contact

XEO IPL 600–850 5–20 ?Automatic None

Cynosure PhotoGenicaV PDL 585 20 0.45 3, 5, 7, 10 Cold air

PhotoGenica PDL 585–595 40 0.5–40 5, 7, 10, 12 Cold air

V-Star

SmartEpill II Nd:YAG 1064 1–200 Up to 100 2, 5, 7, 10 Cold air

Acclaim 7000 Nd:YAG 1064 300 0.4–300 3, 5, 7, 10, 12 Cold air

PhotoLight IPL 400–1200 3–30 5–50 46 × 18, 46 × 10 None

Cynergie IPL/Nd:YAG 595/1064 20/160 0.5–40/ 7 Cold air

0.3–300

DDD Elipse IPL 400–950 Up to 21 0.2–50 10 × 48

DermaMed Quadra Q4 IPL 510–1200 10–20 60–200 33 × 15 None

USA

Fotana Dualis Nd:YAG 1064 Up to 600 5–200 2–10 None

Iridex Apex-800 Diode 800 5–60 5–100 7, 9, 11 Cooling

handpiece

Laserscope Lyra Nd:YAG 1064 5–900 20–100 1–5 Cooling

continuously handpiece

adjustable

Aura KTP 532 1–240 1–50 1–5 Cooling


adjustable

Gemini KTP 532 Up to 100 1–100 1–5 Cooling


adjustable

Nd:YAG 1064 Up to 990 10–100 1–5 Cooling


adjustable

(Continued)



Table 14.2 (Continued)

Pulse Spot

Product Device Wavelength Energy duration diameter

Supplier name typea

(nm) (J) (ms) (mm) Coolingb

Lumenis Quantum IPL 515–1200 Cooled

sapphire

crystal

Vasculite Elite IPL 515–1200 3–90 1–75 35 × 8

Nd:YAG 1064 70–150 2–48 6 Cooled

sapphire

crystal

Lumenis One IPL 515–1200 10–40 3–100 15 × 35, 8 × 15 Cooled

sapphire

crystal

Nd:YAG 1064 10–225 2–20 2 × 4, 6, 9 Cooled

sapphire

Med-Surge Quantel Viridis Diode 532 Up to 110 15–150

ProliteII IPL 550–900 10–50 10 × 20, 20 × 25 None

OpusMed F1 Diode 800 10–40 15–40 5, 7 None

Orion Lasers Harmony Fluorescent IPL 540–950 5–20 10, 12, 15 40 × 16 None

Nd:YAG 1064 35–145 40–60 6 None

Nd:YAG 1064 35–450 10 2 None

Palomar MediLux IPL 470–1400 Up to 45 10–100 12 × 12 None

EsteLux IPL 470–1400 Up to 45 10–100 16 × 46 None

StarLux IPL/Nd:YAG 550–670/870– Up to 700 0.5–500

1400/1064

Quantel Athos Nd:YAG 1064 Up to 80 3.5 4 None

Sciton Profile Nd:YAG 1064 4–400 0.1–200 Contact

Sapphire

Profile BBL IPL 400–1400 Up to 30 Up to 200 30 × 30, 13 × 15

Syneron Aurora SR IPL/RF 580–980 10–30/ Up to 200 12 × 25

2–25RF

Polaris Diode/RF 900 Up to

50/up to

100RF

Galaxy Diode 580–980 Up to Up to 200

140/up to

100RF

WaveLight Mydon Nd:YAG 1064 10–450 5–90 Contact or

cold air

aIPL, intense pulsed light; Nd:YAG, neodymium:yttrium aluminum garnet laser; CuBr, copper bromide (copper vapor) laser; PDL, pulsed dye laser;

diode; diode laser; KTP, potassium titanyl phosphate laser; RF, radiofrequency.

bDCD, dynamic cooling device.

Modified from Goldman MP. Cutaneous and Cosmetic Laser Surgery. Philadelphia: Elsevier, 2006.


delivered as a train of pulses in a 3–4 mm diameter

spot size to trace the vessel until spasm or thrombosis

occurs. Some overlying epidermal scabbing is noted,

and hypopigmentation is not uncommon in dark-

skinned patients.Although individual physicians report

considerable variation in results, usually more than

one treatment is necessary for maximum vessel

improvement, with only rare reports of 100% resolu-

tion of the leg vein.

A comparative study of the 532 nm Nd:YAG laser at

20 J/cm2

delivered as a 50 ms pulse through a contact

cooling and 5 mm diameter spot was made with a

595 nm pulsed dye laser (PDL) at 25 J/cm2, with a

pulse duration of 40 ms, cryogen spray cooling, and

a 3 mm × 10 mm spot.10

After one treatment with the

532 nm Nd:YAG laser, there was 50–75% improve-

ment in 2 of 10 patients and more than 75% improve-

ment in 3 of 10 patients.There was better improvement

in the PDL-treated patients, with 6 of 10 having

50–75% improvement.

Another study compared the 532 nm diode laser

with a 1 mm diameter spot at fluences of 2–32 J/cm2

with the 1064 nm Nd:YAG laser at 1–20 ms pulses

through a 3 mm diameter spot at 130–160 J/cm2

in the

treatment of TM vessels less than 0.3 mm in diameter

that did not respond to sclerotheraopy.11

Two to three

passes were needed to close the vessels with each laser.

Thirty-nine percent of the 532 nm-treated and 55%

of the 1064 nm-treated vessels had better than 50%

lightening.

In short, the 532 nm, long-pulsed, cutaneous, chilled

Nd:YAG laser is effective in treating leg telangiectasia.

As summarized previously, efficacy is technique-

dependent, with a potential for achieving excellent

results. Patients need to be informed of the possibility

of prolonged pigmentation at an incidence similar to

sclerotherapy, as well as temporary blistering and

hypopigmentation that is predominantly caused by

epidermal damage in pigmented skin (type III or

above, especially when tanned).

PULSED DYE LASER, 585 OR 595nm

The PDL has been demonstrated to be highly effective

in treating cutaneous vascular lesions consisting of

very small vessels, including PWS, hemangiomas, and

facial telangiectasia. The depth of vascular damage is

estimated to be 1.5 mm at 585 nm, and 15–20 µm

deeper at 595 nm. Consequently, penetration to the

typical depth of superficial leg telangiectasia may be

achieved.12

However, telangiectasia over the lower

extremities has not responded as well, with less light-

ening and more post-treatment hyperpigmentation.

This may be due to the larger diameter of leg telang-

iectasia as compared with dermal vessels in PWS and

larger diameter feeding reticular veins, as described

previously.

Vessels that should respond optimally to PDL treat-

ment are predicted to be red telangiectasias less than

0.2 mm in diameter, particularly those vessels arising

as a function of TM after sclerotherapy. This is based

on the time of thermocoagulation produced by this

relatively short-pulse laser system (Table 14.1).

In an effort to thermocoagulate larger-diameter

blood vessels, the pulse duration of the PDL has been

lengthened to 1.5–40 ms and the wavelength increased

to 595 nm. This theoretically permits more thorough

heating of larger vessels.These longer pulse durations

are created by using two separate lasers, each emitting

a 2.4 ms pulse. Such LPDLs operate at 595 nm, with

an adjustable pulse duration from 0.5 to 40 ms deliv-

ered through a 5, 7, or 10 mm diameter spot size or a

3mm × 10mm or 5mm × 8mm elliptical spot. Dynamic

cooling with a cryogen spray is also available, with

the cooling spray adjustable from 0 to 100 ms, given

10–40 ms after the laser pulse or as continuous 4°C air

cooling at variable speed.A fluence of 10–25 J/cm2

can

be delivered through a 3 mm × 10 mm or 5 mm ×8 mm spot.

Polla13

evaluated the Candela LPDL on 40 patients

with leg veins 0.05–1.5 mm in diameter. He used a 6

or 20 ms pulse with 7 or 10 mm diameter spot at

10–13 J/cm2

and 6–7 J/cm2, respectively, with a

dynamic cooling device (DCD) setting of 30 ms and

10 ms delay. One to seven treatments were performed

at 3-week intervals. Optimal results were obtained

after two sessions, with 8% having total clearance and

67% having clearance above 40%.All patients had pur-

pura for 7–10 days, 33% had pigmentation for less

than 2 months, and 15% for over 2 months.

Weiss and Weiss14

had similar results using the

Cynosure LPDL on 20 patients with sclerotherapy-

resistant TM.They performed a single treatment with



a 20 ms pulse and a 7 mm diameter spot at 7 J/cm2

for

a total of three stacked pulses with simultaneous cold

air cooling. Of 20 patients, 18 had at least 50%

improvement at 3 months post treatment. Purpura

only occurred in 25% of patients and lasted 10 days.

A longer pulse duration of 40 ms was used on 10

patients with leg telangiectasia up to 1 mm in diameter

at 595 nm with DCD cooling at 25 J/cm2.

10Six

patients had 50–75% improvement and 2 of 10 had

hyperpigmentation that lasted over 3 months.

Our experience is similar to that reported above.

We utilize the LPDL at pulse durations matching the

thermal relaxation time of the leg veins. The energy

fluence used is just enough to produce vessel purpura

and/or spasm. Like Weiss and Weiss,14

we use stacked

pulses to achieve this clinical endpoint.We have used

both LPDL systems and have found them to be compa-

rable. Because of the necessity for multiple treatments

and the significant occurrence of long-lasting hyper-

pigmentation, we reserve the use of the LPDL for

sclerotherapy-resistant, red, telangiectasia less than

0.2 mm in diameter.

DIODE LASERS

Many diode-pumped lasers are now available, includ-

ing a 532, 810, 915, and 940 nm devices (Table 14.2).

Diode lasers generate coherent monochromatic light

through excitation of small diodes. As a result, these

devices are lightweight and portable, with a relatively

small desktop footprint.

Thirty-five patients with spider leg veins were

treated with an 810 nm diode laser with a 12 mm

diameter spot, 60 ms pulse duration, and 80–100 J/cm2,

with a cooled hand-piece.15

Of these 35 patients,15

showed complete disappearance of the spider veins.

Six months after the second laser treatment, 12

patients with partial or no response had dropped out

of the study and 7 patients had a relapse in their leg

veins, with an additional patient having a relapse at 1

year follow-up. Of the 35 patients, 2 had scarring. One

hour of topical EMLA cream had to be applied to limit

pain during treatment.

A 940 nm diode laser has also been used in the treat-

ment of blue leg telangiectasia less than 1 mm in diame-

ter without Doppler evidence of refluxing feeding

veins.16

Twenty-six patients were treated with

300–350 J/cm2

with a 40–70 ms pulse and 1 mm diam-

eter spot, and this gave a clearance of greater than 50%

in 20 patients and greater than 75% in 12 patients.

Slight textural changes were seen in 5 patients and pig-

mentation took several months to resolve in 4 patients.

No cooling was provided except for ice packs after

treatment. In a follow-up of these patients 1 year later,

75% of patients had greater than 75% clearance.17

These outstanding long-term results were not seen

in a separate study using the same laser but with a

variety of pulse durations (10–100 ms) and fluences

(200–1000 J/cm2) through a 0.5 mm diameter spot for

vessels less than 0.4 mm in diameter, a 1 mm diameter

spot for vessels 0.4–0.8 mm in diameter, and a 1.5 mm

diameter spot for vessels 0.8–1.4 mm in diameter.18

Fluences were adapted to have complete vessel clear-

ance without epidermal blanching . No cooling device

was used and patients were evaluated at 1 year. The

largest-diameter vessels had the highest clearance rates,

with 13% of vessels less than 0.4 mm in diameter

clearing by more than 75%, versus 88% of vessels

0.8–1.4 mm in diameter clearing by more than 75%.

Laser therapy was more painful than sclerotherapy in 31

of 46 patients, with equal efficacy being noted by the

patients who had had both forms of treatment.

Finally, a combination diode laser at 915 nm with

radiofrequency (RF) at levels up to 100 J/cm2

has been

used to treat leg telangiectasia. Chess19

treated 25

patients with 35 leg veins 0.3–5 mm in diameter with

60–80 J/cm2

fluence and 100 J/cm2

RF energy through

a 5 mm × 8 mm spot size with 5°C contact cooling in up

to three sessions every 4–10 weeks. He found that 77%

of treated sites exhibited greater than 75% improvement

at 6 months.The average discomfort rating was 7 out of

10. Three sites on three different patients developed

eschar formation without permanent scarring. Another

study treated leg telangiectasia 1–4 mm in diameter with

60–80 J/cm2

fluence and 100 J/cm2

RF energy through

a 5 mm × 8 mm spot size with 5°C contact cooling in

three separate sessions at 2- to 4-week intervals.20

Seventy-five percent of vessels had greater than 50%

improvement and 30% had greater than 75% improve-

ment at 2-month follow-up. Almost no complications

were noted to occur.

In summary, diode lasers are limited by treatment pain

and adverse effects. Of note, unless feeding reticular veins



are treated, the distal treated telangiectasias recur at 6–12

months post treatment. Some authors appear to be able

to achieve better results than others using similar para-

meters.The addition of RF to the diode laser appears to

offer little advantage over the laser alone.

INTENSE PULSED LIGHT

IPL was developed as an alternative to lasers to maxi-

mize efficacy in treating leg veins (PhotoDerm VL,

ESC/Sharplan, now Lumenis Santa Clara, CA). This

device permits sequential rapid pulsing, longer-duration

pulses, and longer penetrating wavelengths than laser

systems.

Theoretically, a phototherapy device that produces

noncoherent light as a continuous spectrum with wave-

lengths longer than 550 nm should have multiple advan-

tages over a single-wavelength laser system. First, both

oxygenated and deoxygenated hemoglobin absorb light at

these wavelengths. Second, blood vessels located deeper

in the dermis are affected.Third, thermal absorption by

the exposed blood vessels should occur with less overly-

ing epidermal absorption, since the longer wavelengths

penetrate deeper and are absorbed less by the epidermis,

including melanin (Fig. 14.2).


800

Average temperature increase across a 0.2-mm deep, 0.05-mm diameter vessel vs wavelength

Average temperature increase across a 2-mm deep, 1-mm diameter vessel vs wavelength

700

600

500

400

300

200

100

400

∆ T

(°C

)∆

T (

°C)

440

480

520

560

600

640

Wavelength (nm)

Wavelength (nm)

680

720

760

800

840

880

920

960

1000

400

440

480

520

560

600

640

680

720

760

800

840

880

920

960

1000

0

0

2

4

6

8

10

12

DeOxy

Oxy

DeOxy

Oxy

Fig.14.2 Average temperature increase across a cutaneous vessel as a function of wavelength for two cases:a shallow capillary

vessel (similar to those found in a port wine vascular malformation) and a deeper (2 mm) and larger (1 mm) vessel typical of a leg

venule.The calculated curves are generated assuming that the main light-absorbing chromophore in the blood is either oxygenated or

deoxygenated hemoglobin.The calculation is carried out for a 10 J/cm2

fluence and does not take into account cooling by heat

conductivity.Note the dramatic shift in the optimal wavelength as a function of vessel depth and diameter.Also note the difference

between oxygenated and deoxygenated hemoglobin.(Reproduced with permission from SclerotherapyTreatment of Varicose and

Telangiectatic Leg Veins,4th edn.Goldman MP,Bergan JB,Guex JJ,eds.Elsevier,London,2006.)


With the theoretical considerations just mentioned,

an IPL in the 515–1000 nm range was used at varying

energy fluences (5–90 J/cm2) and various pulse dura-

tions (2–25 ms) to treat venectasia 0.4–2.0 mm in

diameter.This IPL allows treatment through a quartz

crystal of 8 mm × 35 mm or 8 mm × 15 mm (up to

2.8 cm2) that can be decreased in size to match the

clinical area of treatment. Clinical trials using various

parameters with the IPL, including multiple pulses of

variable duration, demonstrated efficacy ranging from

over 90% to total clearance in vessels less than 0.2 mm

in diameter, 80% in vessels 0.2–0.5 mm in diameter,

and 80% in vessels 0.5–1 mm in diameter.21

The inci-

dence of adverse sequelae was minimal, with hypopig-

mentation occurring in 1–3% of patients, resolving

within 4–6 months. Tanned or darkly pigmented

Fitzpatrick type III patients were more likely to develop

hypopigmentation and hyperpigmentation in addition

to blistering and superficial erosions.These all cleared

over a few months.Treatment parameters found to be

most successful ranged from a single pulse of 22 J/cm2

in 3 ms for vessels less than 0.2 mm or a double pulse of

35–40 J/cm2

given in 2.4 and 4.0 ms with a 10 ms delay.

Vessels between 0.2 and 0.5 mm were treated with the

same double-pulse parameters or with a 3.0–6.0 ms

pulse at 35–45 J/cm2

with a 20 ms delay time.Vessels

above 0.5 mm were treated with triple pulses of 3.5,

3.1, and 2.6 ms with pulse delays of 20 ms at a fluence

of 50 J/cm2

or with triple pulses of 3, 4, and 6 ms with a

pulse delay of 30 ms at a fluence of 55–60 J/cm2.The

choice of a cutoff filter was based on skin color, with

light-skinned patients using a 550 nm filter and darker-

skinned patients a 570 or 590 nm filter.

Treatment of essential telangiectasia, especially on

the legs, is efficiently accomplished with the IPL (Fig.

14.3). A variety of parameters have been shown to be

effective.We recommend testing a few different para-

meters during the first treatment session and using

the most efficient and least painful parameter on

subsequent treatments.

The use of IPL to treat leg veins is encouraging but

far from being easily reproduced. This technology

requires significant experience and surgical ability to

produce good results. Various parameters must be

matched to the patient’s skin type as well as to the

diameter, color, and depth of the leg vein.With older


Fig.14.3 Before and after treatment of essential leg telangiectasia with intense pulsed light. (Reproduced with permission

from Sclerotherapy Treatment of Varicose and Telangiectatic Leg Veins,4th edn.Goldman MP,Bergan JB,Guex JJ, eds.Elsevier,

London,2006.)


machines that do not have integrated cooling through

sapphire crystals, a cold gel must be placed between

the IPL crystal and the skin surface to provide optimal

elimination of epidermal heat. Many have compared

using the IPL to playing a violin. A 2- to 3-year-old

playing a violin will make a squeaky noise, but, with

practice, by the time the child is 7 or 8, he or she will

make beautiful music. Regarding the IPL, it is the art

of medicine that assumes an equal importance to its

science.

Fortunately, for those who do not play musical

instruments, there are now dozens of IPLs available

from many different manufacturers (Table 14.2).

Nd:YAG LASER, 1064 nm

The Nd:YAG laser, 1064 nm, is probably the most

effective laser available to treat leg telangiectasia. In an

effort to deliver laser energy to the depths of leg veins

(often 1–2 mm beneath the epidermis) with thermo-

coagulation of vessels 1–3 mm in diameter, 1064 nm

lasers with pulse durations between 1 and 250 ms have

been developed. However, because of the poor absorp-

tion of hemoglobin and oxyhemoglobin at 1064 nm

wavelength, higher fluences must be used. Depending

on the amount of energy delivered, the epidermis

must be protected to minimize damage to pigment

cells and keratinocytes. Three mechanisms are avail-

able to minimize epidermal damage through heat

absorption. First, the longer the wavelength, the

less energy will be absorbed by melanocytes or

melanosomes. This will allow darker skin types to be

treated with minimum risks to the epidermis due to a

decrease in melanin interaction. Second, delivering

the energy with a delay in pulses greater than the ther-

mal relaxation time for the epidermis (1–2 ms) allows

the epidermis to cool conductively between pulses.

This cooling effect is enhanced by the application to

the skin surface of cold gel that conducts away epider-

mal heat more efficiently than air. Finally, the epider-

mis can be cooled directly to allow the photons to pass

through without generating sufficient heat to cause

damaging effects.

Epidermal cooling can be given in many different

ways. The simplest method is continuous contact

cooling with chilled water, which can be circulated in

glass, sapphire, or plastic housings.The laser impulse is

given through the transparent housing, which should be

constructed to ensure that the laser’s effective fluence is

not diminished.This method is referred to continuous

contact cooling.The benefit is its simplicity.The disad-

vantage is that the cooling effect continues throughout

the time that the device–crystal is in contact on the skin.

This results in a variable degree and depth of cooling,

determined by the length of time the cold housing is in

contact with the skin. This nonselective and variable

depth and temperature of cooling may necessitate

additional treatment energy so that the cooled vessel

will heat up sufficiently to thermocoagulate.

Another method of cooling is contact precooling. In

this approach, the cooling device contacts the epidermis

adjacent to the laser aperture. The epidermis is pre-

cooled and then treated as the handpiece glides along

the treatment area. Because the cooling surface is not in

the beam path, no optical window is required, and bet-

ter thermal contact can be made between the cooling

device and the epidermis.The drawback is the nonre-

producibility of cooling levels and degrees, which are

based on the speed and pressure at which the surgeon

uses the contact cooling device.

Yet another method for cooling the skin is to deliver to

the skin a cold spray of refrigerant that is timed to precool

the skin before laser penetration and also to postcool the

skin to minimize thermal backscattering from the laser-

generated heat in the target vessel.We have termed this

latter effect ‘thermal quenching’. This method repro-

ducibly protects the epidermis and superficial nerve end-

ings. In addition, it acts to decrease the perception of

thermal laser epidermal pain by providing another sensa-

tion (cold) to the sensory nerves. Finally, it allows an effi-

cient use of laser energy because of the relative selectivity

of the cooling spray, which can be limited to the epider-

mis. The millisecond control of the cryogen spray

prevents cooling of the deeper vascular targets and is

given in varying amounts so that epidermal absorption of

heat is counteracted by exposure to cryogen.

Since the target vessel absorbs the 1064 nm wave-

length poorly, a much higher fluence is necessary

to cause thermocoagulation. Whereas a fluence of

10–20 J/cm2

is sufficient to thermocoagulate blood

vessels when delivered at 532 or 585 nm, a fluence of



70–150 J/cm2

is required to generate sufficient heat

absorption at 1064 nm.Various 1064 nm lasers are cur-

rently available that meet the criteria for selectively

thermocoagulating blood vessels, including, among

others, the Lumenis One and Vasculite (Lumenis, Santa

Clara, CA),Varia (CoolTouch Corp., Roseville, CA),

Lyra (Laserscope, San Jose, CA), GentleYAG (Candela,

Wayland, MA), SmartEpil II (Cynosure, Chelmsford,

MA), Harmony (Orion Lasers, FL), Profile (Sciton,

Palo Alto, CA), Mydon (WaveLight, Erlsngen,

Germany), and CoolGlide (Cutera, Burlingame, CA)

(Table 14.2).The long-pulse 1064 nm Nd:YAG lasers

are not all the same.There are variabilities in spot size,

laser output both in fluence and in how the extended

time of the laser pulse is generated), pulse duration,

and epidermal cooling. In addition, although many

claims are made by the laser manufacturers, few well-

controlled peer-reviewed medical studies are available.

Because of the vaariability between the 1064 nm

Nd:YAG lasers, a review of the clinical studies with

each system will be presented separately.

Vasculite

The Vasculite was the first long-pulsed 1064 nm laser

to be approved by the US Food and Drug Administration

(FDA) for vascular treatment. The Nd:YAG 1064 nm

laser is pulsed with IPL technology. Individual pulses

up to 16 ms in length can be delivered as single,

double, or triple synchronized pulses with a total

maximum fluence of 150 J/cm2. The laser beam is

generated in the handpiece and delivered through a

sapphire crystal 6 mm, 9 mm, or 3 mm × 6 mm in size.

Weiss and Weiss,22

Sadick,23

and Goldman24

have

reported excellent results in treating leg telangiectasia

from 0.1 to 3 mm in diameter. Application of a cool

gel to the skin (without cooling of the crystal – which

is not necessary with the most advanced version,

Lumenis 1, which is thermokinetically cooled to 4°C)

and synchronization of the pulses allow epidermal

cooling and protection. In addition, synchronized tim-

ing between pulses can be tailored to the thermal

relaxation times of blood vessels.

Weiss and Weiss22

treated 30 patients who had been

dissatisfied with previous leg vein treatments with

either sclerotherapy or other laser light or IPL.A single

14–16 ms pulse at 110–130 J/cm2

was given to treat

vessels 1–3 mm in diameter. A double pulse of 7 ms

separated by 20–30 ms at a fluence of 90–120 J/cm2

was used to treat vessels 0.6–1 mm in diameter, and a

triple synchronized pulse of 3–4 ms at a fluence of

80–110 J/cm2

was used to treat vessels 0.3–0.6 mm in

diameter. Immediate contraction of the vessel was

used as an endpoint of treatment, followed by urtica-

tion. Immediate bruising from vessel rupture occurred

in 50% of vessels. At 3 months after treatment, the

majority of sites improved by over 75% (Fig. 14.4).

Hyperpigmentation was noted in 28% of patients at

the 3-month follow-up. In short, this report demon-

strated successful treatment of otherwise-difficult ves-

sels, and mirrors our experience. Weiss and Weiss25

reported on 3-year results in the treatment of leg

telangiectasia 0.3–3 mm in diameter at slightly higher

fluences of 110–150 J/cm2. They found an average

75% improvement in 2.38 treatments. Sixteen percent

of patients developed pigmentation which resolved at

6 months, and 4% developed TM.

Sadick26

reported on 12-month follow-up in 25

patients with leg veins with a fluence of 120 J/cm2

given through a 6 mm diameter spot in a 7 ms double

pulse to vessels 0.2–2 mm in diameter and as a single

pulse of 14 ms and a fluence of 130 J/cm2

to vessels

2–4 mm in diameter. Using these parameters, 64% of

patients could achieve 75% or greater clearance in

three treatments. Two of the 25 treated patients who

had less than 25% vessel clearance developed a recur-

rence of the veins within 6–12 months. Sixteen per-

cent of patients developed pigmentation, which lasted

4 months, and 8% developed TM.

CoolTouch Varia

The CoolTouch Varia combines a multiple train of

pulses to generate a pulse width from 10 to 300 ms

bursts. Fluences of up to 150 J/cm2

can be generated.

A 3–10 mm diameter beam is delivered through a

fiberoptic cable. Dynamic cooling is given with a cryo-

gen spray that can be delivered before, during, and/or

after the laser pulse. The cooling spray can be varied

from 5 to 200 ms and can be given in 5–30 ms bursts in

5 ms intervals before and/or after the laser pulse. In

this manner, in the treatment of larger or deeper



vessels, the postcooling quenching cryogen spray can

be given 20–30 ms after the laser pulse to coincide

with conduction of heat absorbed by the vessel propa-

gating back to the epidermis. More superficial and

smaller vessels require a shorter delay in the postlaser

cooling spray of 5 ms. We have found this laser to be

therapeutically beneficial in treating leg telangiectasia

0.1–2 mm in diameter (Fig. 14.5). A comparative

study of two long-pulsed 1064 nm Nd:YAG lasers was

performed on 11 patients with leg telangiectasia with-

out feeding (or with previously treated) feeding retic-

ular veins.The CoolTouch Varia was used with a 6 mm

diameter spot size at a fluence of 135 J/cm2

with a

25 ms pulse and precooling of 5 ms and postcooling of

15 ms. The CoolGlide laser was used with a 5 mm

diameter spot, 25 ms pulse at 200 J/cm2

and contact

cooling. Both lasers produced comparable clearing of

75% in all treated vessels. However, the CoolGlide

laser was significantly more painful.27

Two papers were published on the same 23 of 30 leg

vein patients (completing the study) treated with the

CoolTouch Varia.28,29

Greater than 75% improvement

was noted at 85% of treated sites.Transient pigmenta-

tion was noted in 6 of 23 patients, with TM in 1 of 23

patients. Fluences of 150 J/cm2

were used for all-

diameter veins, with a 25 ms pulse duration on veins

less than 1.5 mm in diameter and 50–100 ms on veins

1.5–3 mm in diameter. Patients received up to two

treatments 4–6 weeks apart. One to three passes were

required to blanch the targeted vessels. Laser spot

diameters and the time of pre and/or pulse cooling

was not noted in either of the two papers. Patients

who had previously had treatment with nonhypertonic

saline sclerotherapy preferred sclerotherapy over laser

because of the increased pain with the laser.

A direct comparison of the CoolTouch Varia with scle-

rotherapy utilizing sodium tetradecyl sulfate (STS) was

performed on 20 patients with size-matched superficial

leg telangiectasia 0.5–1.5 mm in diameter.30

Laser treat-

ments were given through a 5.5 mm diameter spot at

125–150 J/cm2

with a 25 ms pulse duration. Precooling

ranged from 0 to 5 ms and postcooling from 20 to 50 ms

with a delay of 5–20 ms.The endpoint of laser treatment

was vessel contraction. Sclerotherapy with STS 0.25%

was followed by 48 hours of 20–30 mmHg graduated

compression stockings. Sclerotherapy-treated patients

had a significantly better response in fewer treatments,

with comparable adverse effects.

CoolGlide

The CoolGlide can deliver fluences up to 100 J/cm2

through a 10 mm diameter spot. The pulse duration

can be varied continuously from 10 to 100 ms. Unlike

the other two systems, which can deliver each burst at

a 1 Hz speed, the CoolGlide can deliver pulses at 2 Hz.

Cooling is provided by a contact system that glides in


Fig.14.4 Treatment of leg telangiectasia with theVasculight at the parameters specified in the text. (a) Before treatment.

(b) 60 days after treatment. (Courtesy of Robert Weiss MD and reproduced with permission from Sclerotherapy Treatment of

Varicose and Telangiectatic LegVeins,4th edn.Goldman MP,Bergan JB,Guex JJ, eds.Elsevier,London,2006.)

a b


front of the laser beam so that 2 cm of skin is pre-

cooled before the laser aperture glides over the treat-

ment site. We have also found this system to be

effective in treating leg telangiectasia 0.1–3 mm in

diameter.27

However, the lack of effective, repro-

ducible cooling can lead to the production of epider-

mal scars more often than the other 1064 nm laser

systems, as well as an increase in procedural pain.

Fifteen women with 21 sites of leg telangiectasia

0.25–4 mm in diameter were treated twice at 6–8

weeks with the CoolGlide using a 7 mm spot, fluences

of 90–160 J/cm2

and pulse durations of 10–50 ms.31

Significant improvement was seen in 71% of sites, but

hyperpigmentation was present in 61% of sites at 3-

month follow-up. A second study on 20 patients with

reticular veins 1–3 mm in diameter was performed

using 100 J/cm2

and 50 ms pulse, without mention of

the laser spot diameter.32

Although 66% of the vessels

cleared more than 75% with one treatment at 3

months, pain was significant, especially without the

use of EMLA cream applied for 1 hour. Unfortunately,

longer follow-up was not reported.

Lyra

The Lyra long-pulse 1064 nm Nd:YAG laser was

used to treat 20 patients with leg telangiectasia

0.5–5 mm in diameter with 100–200 J/cm2

at

50–100 ms with a 3–5 mm diameter spot and one to

four treatments.33

Comparable telangiectasias on the

same patient were treated with one treatment of

STS 0.6%. No compression was used. Even at these

parameters with excessive concentration of STS

without compression, and four laser treatments ver-

sus one sclerotherapy treatment, adverse effects and

treatment efficacy were not statistically different

between the two treatment modalities. Patient

surveys found that 35% preferred laser and 45%

preferred sclerotherapy.

Sadick34

also evaluated the Lyra with a 30–50 ms

pulse duration, 1.5 mm diameter, 400–600 J/cm2

for

red vessels and a 50–60 ms pulse, 1–3 mm diameter

spot, and 250–370 J/cm2

for blue vessels through a

4°C cold window for three treatments. At 6 months,

80% of vessels had greater than 75% clearance. This

was a limited study on 10 patients. Two of the 10

patients had pigmentation lasting up to 6 months, and

TM occurred in 1 of the 10. Moderate discomfort was

experienced by all patients.

Quantel Medical Multipulse mode

The most recent development in long-pulse 1064 nm

Nd:YAG technology has been the production of a


Fig.14.5 (a) After sclerotherapy – an ulceration occurred that is covered with an occlusive dressing. (b) After treatment of a

foot telangiectasia with the CoolTouch Varia at 150 J/cm2

with a 50 ms pulse and 5 ms of precooling 10 ms before the laser pulse,

followed by a 10 ms cooling burst 10 ms after the laser pulse.Note the complete clearing 60 days after treatment. (Reproduced

with permission from Sclerotherapy Treatment of Varicose and Telangiectatic Leg Veins,4th edn.Goldman MP,Bergan JB,Guex JJ,

eds.Elsevier,London,2006.)

a b


nonuniform pulse sequence mode device with contact

cooling to 5°C.35

This device has a fluence of

300–360 J/cm2

through a 2 mm diameter spot. The

rationale for multiple pulsing is to convert oxyhemoglo-

bin to met-hemoglobin, which will be absorbed

better at 1064 nm.The pulse duration consists of a series

of three 3.5 ms pulses separated by 250 ms between each

pulse; 60% of the energy is delivered in the first pulse,

with 20% in each of the next two pulses. In an initial

study on 11 patients with blue leg veins 1–2 mm in

diameter, patients had up to three treatments at 6-week

intervals. There was 98% clearance after three treat-

ments, with moderate pain with each treatment.

To summarize, we have found the 1064 nm long-

pulsed Nd:YAG lasers to be beneficial in the treatment

of leg telangiectasia not responsive to sclerotherapy or

other lasers. The benefit in using a 1064 nm laser is

that its longer wavelength can penetrate more deeply,

allowing effective thermosclerosis of vessels up to

3–4 mm in diameter. In addition, the 1064 nm wave-

length permits treatment of patients of skin types I–VI

with or without a tan, since melanin absorption is min-

imal. The 1064 nm long-pulse laser systems are not

entirely without side-effects, however. Cutaneous

burns with resulting ulcerations, pigmentation, and

TM have been observed with each of these systems as

parameters are being tested. The dynamically cooled

1064 nm Nd:YAG laser appears to produce the best

clinical resolution, with less pain and fever adverse

effects than other long-pulse 1064 nm lasers.

However, sclerotherapy still provides better results

with fewer treatments, less pain, and comparable adverse

effects to lasers. Thus, the reader should evaluate the

latest studies to ensure ideal results.

COMBINATION/SEQUENTIAL 595 nm

PDL AND 1064 nm Nd:YAG – CYNERGY

The latest device to enter the market uses a novel

sequential 595 nm PDL pulse followed by a 1064 nm

Nd:YAG laser pulse. This laser, Cynergy (Cynosure,

Westford, MA), is presently undergoing clinical test-

ing by our group, among others. The rationale for

enhanced efficacy is that the 595 nm pulse generates

met-hemoglobin, which absorbs more strongly at the

1064 nm wavelength.Thus, lower energies from both

lasers can be used, with the possibility of less pigmen-

tation and adverse sequelae. Preliminary experience is

promising in treating bright red vessels less than

0.1 mm in diameter, which are the most difficult

vessels to treat with sclerotherapy.

CONCLUSIONS

Since sclerotherapy is relatively cost-effective com-

pared with laser or IPL treatment, when is it appro-

priate to use this advanced therapy? Obviously,

needle-phobic patients will tolerate the use of this

technology, even though the pain from lasers and IPL

is more intense than from sclerotherapy with all but

hypertonic solutions. Patients who are prone to

TM are also appropriate candidates. Vessels below

the ankle are particularly appropriate to treat with

light, since sclerotherapy has a relatively high inci-

dence of ulceration in this area because of the higher

distribution of arteriovenous anastomosis. Finally,

patients who have vessels that are resistant to scle-

rotherapy are excellent candidates.An efficacy of 75%

clearance with two to three IPL treatments occurred

in sclerotherapy-resistant vessels.36

The optimal efficacy in treating common leg telang-

iectasia uses sclerotherapy to treat the feeding venous

system and a laser or IPL to seal superficial vessels to

prevent extravasation with resulting pigmentation,

recanalization, and TM.

So, is there a single laser that can adequately treat

leg veins? The answer is both yes and no. Yes, because

lasers are now available with pulse durations optimized

to treat various sized blood vessels. One can select vir-

tually any wavelength from 532 to 1064 nm, as well as

a broad spectrum of IPL. It has been demonstrated

that any wavelength can be used effectively, as long as

the pulse duration matches the diameter of the vessel

and the appropriate fluence is utilized. This also

assumes that the epidermis will be protected from

nonspecific thermal effects by a variety of cooling and

pulsing scenarios. One can cool the skin directly with a

contact probe before and after the laser pulse or

through a sapphire window before, during, and after

the laser pulse. Cooling can also be given dynamically



with a cryogen spray before, during, or after the laser

pulse. Most patients prefer dynamic cooling, as it pro-

vides the highest degree of pain control. Contact cool-

ing has the unpredictability of adequately cooling the

epidermis, so that, unless optimal technique is used,

epidermal burns will occur.

However, the answer is also no, as the lasers

presently available still require skillful use for safe and

effective treatment. The laser of the future was

detailed in a September 2001 publication.37

This ideal

laser will have a built-in thermal sensor to detect both

epidermal and vascular heating. This will automati-

cally regulate the fluence so that the vessel is com-

pletely thermocoagulated, as well as epidermal

cooling so that the epidermis is kept below a damag-

ing temperature threshold. Even better would be an

infrared sensor that would determine the location of

feeding dermal vessels so that they too can be treated

along with the visible telangiectasia. One could imag-

ine, in the future, the patient placing the leg into a

laser machine that would map the visible veins to be

thermocoagulated and automatically treat the entire

superficial venous network. At present, the only bar-

rier preventing the development of such a laser is

money and the willingness of a company to produce a

machine of this type.

REFERENCES

1. Anderson AR, Parrish JA. The optics of human skin.


2. Weiss RA,Weiss MA. Resolution of pain associated with

varicose and telangiectatic leg veins after compression

sclerotherapy. J Dermatol Surg Oncol 1990;16:333–6.

3. Bernstein EF. Clinical characteristics of 500 consecutive

patients presenting for removal of lower extremity spider

veins. Dermatol Surg 2001;27:31–3.

4. Goldman MP, Bergan JB, Guex JJ, eds. Sclerotherapy

Treatment of Varicose and Telangiectatic Leg Veins, 4th

edn. London: Elsevier, 2006.

5. Goldman MP. Laser and sclerotherapy treatment of leg

veins: my perspective on treatment outcomes. Dermatol

Surg 2002;28:969.

6. Braverman IM. Ultrastructure and organization of the

cutaneous microvasculature in normal and pathologic

states. J Invest Dermatol 1989;93(Suppl):2S–9S.

7. Wokalek H, Varscheidt W, Martay K, Ledor O.

Morphology and localization of sunburst varicosities: an

electron microscopic and morphometric study.

J Dermatol Surg Oncol 1989;15:149–54.

8. Bodian EL. Sclerotherapy. J Dermatol Surg Oncol

1989;15:156–61.

9. Adrian RM. Treatment of leg telangiectasias using a

long-pulse frequency-doubled neodymium:YAG laser at

532 nm. Dermatol Surg 1998;24:19–23.

10. Woo WK, Jasim ZF, Handley JM. 532-nm Nd:YAG and

595-nm pulsed dye laser treatment of leg telangiectasia using

ultralong pulse duration. Dermatol Surg 2003;29:1176–80.

11. Raskin B, Fany RR. Laser treatment for neovascular

formation. Lasers Surg Med 2004;34:189–92.

12. Garden JM, Tan OT, Kerschmann R, et al. Effect of dye

laser pulse duration on selective cutaneous vascular

injury. J Invest Dermatol 1986;87:653–7.

13. Polla LL. Treatment of leg telangiectasia with a 595 nm

LPDL. Lasers Surg Med 2002;14(Suppl):78.

14. Weiss RA, Weiss MA. Long pulsed dye laser (LPDL)

treatment of resistant telangiectatic matting of the legs.

Lasers Surg Med 2002;14(Suppl):86.

15. Wollina U, Konrad H, Schmidt W-D, et al. Response of

spider leg veins to pulsed diode laser (810 nm): a clinical,

histological and remission spectroscopy study. J Cosmet

Laser Ther 2003;5:154–62.

16. Kaudewitz P, Kloverkorn W, Rother W. Effective treat-

ment of leg vein telangiectasia with a new 940 nm diode

laser. Dermatol Surg 2001;27:101–6.

17. Kaudewitz P, Kloverkorn W, Rother W.Treatment of leg

vein telangiectasias: 1-year results with a new 940 nm

diode laser. Dermatol Surg 2002;28:1031–4.

18. Passeron T, Olivier V, Duteil L, et al. The new 940-

nanometet diode laser: an effective treatment for leg

venulectasia. J Am Acad Dermatol 2003;48:768–74.

19. Chess C. Prospective study on combination diode laser

and radiofrequency energies (ELOSTM

) for the treatment

of leg veins. J Cosmet Laser Ther 2004;6:86–90.

20. Sadick NS, Trelles MA. A clinical and histological, and

computer-based assessment of the Polaris LV, combina-

tion diode, and radiofrequency system, for leg vein treat-

ment. Lasers Surg Med 2005;36:98–104.

21. Schroeter CA,Wilder D, Reineke T, et al. Clinical signifi-

cance of an intense, pulsed light source on leg telangiec-

tasias of up to 1 mm diameter. Eur J Dermatol 1997;7:38.

22. Weiss RA,Weiss MA. Early clinical results with a multi-

ple synchronized pulse 1064 nm laser for leg telangiec-

tasias and reticular veins. Dermatol Surg 1999;25:

399–402.

23. Sadick NS.The utilization of a new Nd:YAG pulsed laser

(1064 nm) for the treatment of varicose veins. Lasers

Med Surg 1999;11(Suppl):21.

24. Goldman MP. Laser treatment of leg veins with 1064 nm

long-pulsed lasers. Cosmet Dermatol 2000;13:27–30.




25. Weiss MA, Weiss RA. Three year results with the long

pulsed Nd:YAG 1064 laser for leg telangiectasia.

Presented at the American Society for Dermatologic

Surgery Annual Meeting, Dallas,TX, October, 2001.

26. Sadick NS. Long-term results with a multiple synchro-

nized-pulse 1064 nm Nd:YAG laser for the treatment of

leg venuelectasias and reticular veins. Dermatol Surg

2001;27:365–9.

27. Bowes LE, Goldman MP.Treatment of leg telangiectasias

with a 1064 nm long pulse Nd:YAG laser using dynamic

vs contact cooling: a comparative study. Lasers Surg Med

2002;14(Suppl):40.

28. Eremia S, Li CY. Treatment of leg and face veins with a

cryogen spray variable pulse width 1064-nm Nd:YAG

laser – a prospective study of 47 patients. J Cosmet Laser

Ther 2001;3:147–53.

29. Li CY, Eremia S. Treatment of leg and face veins with a

cryogen spray, variable pulse width 1064 nm Nd:YAG

laser – a prospective study of 47 patients. Am J Cosmet

Surg 2002;19:3–8.

30. Lupton JR, Alster TS, Romero P. Clinical comparison of

sclerotherapy versus long-pulsed Nd:YAG laser treat-

ment for lower extremity telangiectases. Dermatol Surg

2002;28:694–7.

31. Rogachefsky AS, Silapunt S, Goldberg DJ. Nd:YAG laser

(1064 nm) irradiation for lower extremity telangiectasias

and small reticular veins: efficacy as measured by vessel

color and size. Dermatol Surg 2002;28:220–3.

32. Omura NF, Dover JS,Arndt KA, Kauvar ANB.Treatment

of reticular leg veins with a 1064 nm long-pulsed

Nd:YAG laser. J Am Acad Dermatol 2003;48:76–81.

33. Coles MC,Werner RS, Zelickson BD. Comparative pilot

study evaluating the treatment of leg veins with a long

pulse Nd:YAG laser and sclerotherapy. Lasers Surg Med

2002;30:154–9.

34. Sadick NS. Laser treatment with a 1064-nm laser for

lower extremity class I–III veins employing variable spots

and pulse width parameters. Dermatol Surg 2003;29:

916–19.

35. Mordon S, Brisot D, Fournier N. Using a ‘non uniform

pulse sequence’ can improve selective coagulation with a

Nd:YAG laser (1.064 µm) thanks to met-hemoglobin

absorption: a clinical study on blue veins. Lasers Surg

Med 2003;32:160–70.

36. Weiss RA,Weiss MA. Photothermal sclerosis of resistant

telangiectatic leg and facial veins using the PhotoDerm

VL. Presented at the Annual Meeting of the Mexican

Academy of Dermatology, Monterey, Mexico, April 24,

1996.

37. Goldman MP. Are lasers or non-coherent light sources

the treatment of choice for leg veins? A look into the

future. Cosmet Dermatol 2001;14:58–9.


HISTORY

The use of light therapy began in 1400 BC when Hindus

first applied naturally occurring plant psoralens to

their skin followed by ambient sun exposure to treat

vitiligo.1

Later, groups as diverse as the ancient

Egyptians, Greeks, and Romans used photosensitizing

agents plus light to treat a multitude of skin diseases.

However, it was not until 1984 that Lahmann in

Germany invented the first artificial light source to

treat skin diseases.2

Since then, options to treat skin

disease with an activating source and light have vastly

multiplied. Most recently, the technique has been

further honed with the advent of psoralen plus

UVA treatment,3

extracorporeal photophoresis for

cutaneous T-cell lymphoma,4

and high dose UVA-1

phototherapy for atopic dermatitis.5

In the year 1900 a German medical student, Oscar

Raab, noted that acridine orange was lethal for para-

mecia only when combined with sunlight. Seven years

later, Hermann von Tappeiner coined the term ‘photo-

dynamic reaction’ to describe reactions that require a

photosensitizing agent, oxygen, and light.6These three

components are the required ingredients of photo-

dynamic therapy (PDT) to this day.

MECHANISM

PDT is a two-step system that requires the presence of

a photosensitizing agent, photoactive wavelengths of

light, and oxygen. First, the photosensitizing agent is

delivered orally, topically, or intravenously for uptake

by the patient’s target cells. Second, a photon of light is

absorbed by the photosensitizer, which leads to its

activation. Once activated, the photosensitizer trans-

fers its energy to a singlet oxygen species, leading to

destruction of the target cell.7

Early descriptions of PDT involved the use of eosin

as a photosensitizing agent and light to treat skin can-

cer, lupus vulgaris, and condyloma lata.7,8

Since that

time, porphyrins have become the photosensitizer of

choice. Initial work focused on hematoporphyrin and

hematoporphyrin derivatives. Unfortunately, these

agents persisted in the body for many months, subject-

ing patients to undesirable prolonged phototoxicity.

Dermatologists have since focused on photosensitizers

such as δ-aminolevulinic acid (also known as 5-

aminolevulinic acid, ALA) and its more lipophilic

methyl ester (MAL).9These topical porphyrin precur-

sors cause less phototoxicity and are more readily

cleared by the body. Moreover, topical administration

of the photosensitizer is a logical approach, since the

skin is a readily accessible target.10

The most common topically applied photosensitiz-

ing agent in the USA is ALA, the first intermediate in

the heme biosynthesis pathway. Topical application of

ALA bypasses the rate-limiting step of heme biosynthe-

sis11

(Fig. 15.1).When ALA enters cells, it is converted

to the endogenous photosensitizer protoporphyrin IX

(PpIX) and permits a buildup of the latter.10

Activation

of PpIX by the appropriate visible wavelength of light

results in the production of cytotoxic oxygen free

radicals (singlet oxygen). Singlet oxygen is a highly

reactive excited molecule that irreversibly oxidizes

essential cellular components, causing tissue injury

and necrosis.12

PDT also affects the microvasculature

and immune system.Vascular effects include vasocon-

striction of the arterioles within a tumor, reduction of

erythrocyte flow in nearby venules, and thrombosis

of tumor vessels leading to ischemia and vascular

15. Photodynamic therapy

Papri Sarkar and Ranella Hirsch


compromise. Direct cell killing and immunological

effects, including the production of interleukin-1β(IL-1β), IL-2, tumor necrosis factor (TNF), and

granulocyte colony-stimulating factor (G-CSF), also

occur.7

Of note, singlet oxygen can also target and destroy

the photosensitizer itself, limiting further effect.

Because the ALA–PDT reaction is relatively short-

lived, any photosensitivity resolves relatively rapidly.

Resolution occurs within 24–48 hours after treat-

ment. Depending upon the condition to be treated,

the time of application of ALA varies.

The goal of PDT is the selective destruction of dis-

eased cells. Exogenously applied ALA preferentially

accumulates in pilosebaceous units and abnormal ker-

atinocytes, helping to target abnormal cells while pre-

serving normal structures.13

In addition, targeting of

specific lesional tissue is possible by selection of the

appropriate wavelength of light. PpIX has a maximum

absorption peak at 410 nm and smaller ones at 510,

545, 585 and 635 nm14,15

(Fig. 15.2). In general, the

longer the wavelength (up to 850 nm), the deeper is

its penetration into tissue.11

With this dual selectivity,

tissue damage to unaffected bystander tissue is greatly

minimized.

Concern regarding carcinogenesis arises with all

new therapeutic modalities. Because most photosensi-

tizers do not accumulate in cell nuclei, PDT generally

has a low potential for causing DNA damage, muta-

tions, and carcinogenesis.16

LASERS AND LIGHT SOURCES

Both coherent and noncoherent light sources with

suitable spectral characteristics and high output can be


ALA

ALA dehydratase

Porphobilinogen

Porphobilinogendeaminase

Uroporphyrinogen IIIcosynthase

Hydroxymethylbilane

ALA synthase(note-limiting step)

Heme

Ferrochelataseand Fe2+

Protoporphyrinogen IX

Protoporphyrinogenoxidase

Coproporphyrinogen IIIoxidase

Coproporphyrinogen III

Uroporphyrinogen IIIdecarboxylase

Uroporphyrinogen III

Glycine andsuccinyl CoA

NEGATIVE FEED BACK

TopicalALA orMAL

Pp

Fig.15.1 The heme biosynthesis pathway.Production of δ-aminolevulinic acid (ALA) is the rate-limiting step in this pathway.

Exogenous ALA or methyl δ-aminolevulinate (MAL) bypasses this step and drives heme synthesis, producing the endogenous

photosensitizer protoporphyrin IX (PpIX).


used in PDT. As noted in Fig. 15.3, the breadth of the

PpIX absorption spectra allows a variety of light

sources for PDT. Since longer wavelengths generally

allow for deeper tissue penetration, one can selectively

target different epithelial levels. For example, blue

light in the 410 nm range is appropriate for superficial

skin targets, whereas dermal targets require activation

by longer-wavelength light sources (>600 nm).

CLINICAL APPLICATIONS

A critical review of the cosmetic dermatology litera-

ture reveals a fundamental difficulty in assessing PDT

data. Variations between studies are routinely noted

because there are no set protocols for the majority of

conditions evaluated. Differences between methods

include the photosensitizer utilized, skin preparation,

incubation times of photosensitizers, and light sources

and their settings. Much of the data are anecdotal in

nature. Thus, a critical flaw is the lack of meaningful

statistical analysis proving scientific significance. In

addition, almost all studies have limited follow-up

intervals, making assessment of recurrence rates prob-

lematic. Recently, a number of controlled clinical

trials with statistical analysis have been reported in

which PDT has held up favorably.

PHOTOREJUVENATION

The visible signs of photodamage are characterized by

wrinkling, coarse skin texture, pigmentary alterations,

telangiectases, and, in some cases, actinic keratosis

(AK). Multiple investigators have reported the benefits

of ALA–PDT on photodamage. Light sources described

include multiple intense pulsed light sources with the

delivery of filtered wavelengths of noncoherent light

(IPL), combination IPL and radiofrequency (RF)

devices, the pulsed dye laser (PDL), and the potassium

titanyl phosphate (KTP) laser.11

In addition, various

authors have reported on the benefits of ALA in combi-

nation with blue light, IPL, and PDL to treat actinic

keratoses (AK) (Fig. 15.4).

Ruiz-Rodriguez et al18

reported on 17 patients with

varying degrees of photodamage and AK treated with

two treatments of ALA–PDT using IPL as a light

source. Patients were treated with a 615 nm cutoff

filter and total fluence of 40 J/cm2

in a double-pulse

mode of 4.0 ms with a 20 ms interpulse delay.Thirty-

three of 38 AK disappeared with two treatments of

ALA–PDT.Treatments were well tolerated. Erythema

and crusting took 1 week to resolve. Although no

Photodynamic therapy 175

0

0.5

1.0

1.5

2.0

300 350 400 450 500 600550 650

Wavelength (nm)

700

2.5

Ab

sorp

tio

n (

arb

itra

ry u

nit

s)

Fig.15.2 Protoporphyrin IX absorption spectrum.There is

a maximum absorption peak at 410 nm and smaller ones at

510,545,585,and 635 nm.

0

0.5

1.0

1.5

2.0

300 350 400 450 500 600550 650

Wavelength (nm)

IPL 560–1200 nm

PDL 585–595 nm

700

2.5

Ab

sorp

tio

n (

arb

itra

ry u

nit

s)

BLU-U Clearlight

417–432 nm

KTP laser532 nm

Fig.15.3 The wide range in the absorption spectrum of

protoporphyrin IX allows a variety of light sources to be used

for photodynamic therapy.KTP,potassium titanyl phosphate;

PDL,pulsed dye laser; IPL, intense pulsed light. (Reproduced

from Gold MH.5-aminolevulinic acid in photodynamic

therapy. An exciting future.US Dermatology Review

2006;1:81–8717

with permission.


statistical analysis or coding of photoaging parameters

was reported, cosmetic results were described as

‘excellent’ in all patients, with no resulting pigmen-

tary alterations or scarring.

Alster et al19

subsequently performed a comparative

split-face study pairing IPL alone versus ALA–IPL.Ten

patients with mild to moderate photodamage were

recruited. The patients were treated with 60 minutes

of ALA followed by IPL to one-half of the face and IPL

alone on the contralateral side. Two treatments were

delivered at 4-week intervals. Higher clinical improve-

ment scores were noted on the combination ALA–IPL-

treated areas. Mild edema, erythema, and desquama-

tion were observed on the half of the face where ALA

was applied. No scarring or unwanted pigmentary

alteration was seen. The authors concluded that PDT

with combination topical ALA–IPL is safe and more

effective for facial rejuvenation than IPL treatment

alone.

In 2005, Dover et al20

published a prospective, ran-

domized, controlled, split-face study with statistical

analysis comparing ALA–IPL versus IPL alone.Twenty

patients with at least a modest degree of photoaging

were included. Patients were treated three times at

3-week intervals within a split-face protocol with

ALA–IPL to one side and IPL alone to the contralateral

side (fluence 23–28 J/cm2, with cold contact epidermal

cooling). Subsequently, all patients were treated two

additional times at 3-week intervals with full-face IPL

alone. Photodamage variables were assessed by an

independent investigator before each treatment, as

well as 4 weeks after the final treatment. Satisfaction

with treatment was rated by both subjects and a

blinded investigator. In addition, tolerability was

assessed by unblinded investigators at every visit.The

authors reported statistically significant improvements

in global photoaging and mottled pigmentation with

ALA–IPL versus IPL alone. In addition, both the

blinded investigators and subjects preferred the

benefits of the combined ALA–IPL treatment.

Interestingly, adverse effects and tolerability did not

differ significantly between the IPL-only treated areas

and the areas treated with ALA–IPL.

In June 2006, Gold et al21

published another split-

face trial with ALA–IPL versus IPL alone, but did

not include statistical analysis. Sixteen patients with

mild to moderate photodamage were treated with

ALA–IPL and IPL alone (34 J/cm2). Patients received

treatments 1 month apart and were followed 1 month

and 3 months after final treatment. Photographs and

grading of photodamage were performed by a blinded

investigator. For all photoaging parameters, greater


Fig.15.4 Photorejuvenation using δ-aminolevulinic acid (ALA) followed by intense pulsed light (IPL) and radiofrequency

(RF).The patient received two treatment sessions.The ALA incubation time was 30 minutes,which was followed by IPL at

18 J/cm2

and RF at 18 J/cm2, each in a short pulse. (a) Before treatment. (b) After treatment. (Courtesy of Neil S Sadick.)

ba


improvement was seen on the side of the face treated

with ALA–IPL. For example, ALA–IPL showed

55% versus 29.5% improvement in crow’s feet and

tactile skin roughness and 60% versus 37% in mottled

hyperpigmentation. Adverse effects included erythema

and edema, which resolved in all patients without

sequelae.

Butler et al22

compared ALA–IPL and ALA–KTP

for photoaging with a split-face trial, but again, did

not perform statistical analysis. Seventeen patients

with prominent dyschromias and/or discrete telang-

iectases were enrolled and treated once on each side

of the face. Subjects were evaluated and pho-

tographed 1 week and 1 month after treatment and

photographs were reviewed by a panel of blinded

observers. At 1 month, the average improvement for

the ALA–IPL side was 38% for vascular lesions

and 35% for pigmented lesions as scored by indepen-

dent evaluators. The average improvements for the

ALA–KTP side were 42% and 30%, respectively.

Patients rated the two devices very similarly, with

global improvement scores of 66% for ALA–IPL ver-

sus 61% for KTP. However, a majority of patients

found the KTP to be slightly more painful and expe-

rienced greater postprocedure swelling. The authors

concluded that both KTP and IPL provided marked

improvement in vascular and pigmented dyschromias

after one treatment.

Marmur et al23

evaluated tissue samples in an

attempt to correlate clinical improvement with histo-

logical changes in patients treated with PDT. Seven

subjects with minimal photodamage were treated with

ALA–IPL versus IPL alone in a split-face protocol.

Pre- and post-treatment biopsies were analyzed for

changes in collagen by electron microscopic ultra-

structural analysis.An increase in type I collagen fibers

was seen after treatment in both sides, but patients

pretreated with ALA showed a greater increase in type

I collagen formation.

SEBACEOUS GLAND HYPERPLASIA

Sebaceous gland hyperplasia (SGH) is a common,

benign proliferation of sebaceous glands, which occurs

predominantly on the face. Sebaceous glands increase

with age and are often of cosmetic concern to

patients.24

Treatment with the PDL alone has shown

promising results in two patients with SGH.25

In addi-

tion, studies have shown that PpIX accumulates in

pilosebaceous units.20,26

Based on these findings, the

effect of PDT on sebaceous hyperplasia and acne has

recently been investigated. Light sources have included

polychromatic light from a slide projector,27

red

light,28

PDL,29

blue light alone,30

and blue light/IPL.31

Horio et al27

treated one patient with multiple

lesions.They pretreated papules for 4 hours with ALA

and then exposed the patient to the light of a slide pro-

jector through a red glass filter. This was repeated

three times at 1-week intervals.The authors reported

that small papules nearly disappeared and larger

papules became smaller but did not completely

resolve. One year after treatment, there was no recur-

rence of any lesions. Interestingly, prior to treating

with the light source, the authors also excised one

papule for fluorescence microscopy. This showed red

fluorescence of topically applied ALA into the hyper-

plastic sebaceous gland.

Alster et al29

reported on 10 patients with at least

three prominent sebaceous hyperplasia papules who

received ALA–PDL (595 nm) versus no treatment or

PDL alone. Patients were evaluated at 1 and 3 months

after the final treatment. No patients experienced

adverse reactions with the topical ALA per the investi-

gators. Unfortunately, results were not shown in table

form and control lesions did not receive consistent

treatment (some were treated with PDL while others

were untreated).At 3-month follow-up, seven patients

had cleared with one treatment, while three patients

cleared with two.

Richey et al30

treated 10 patients with SGH with

ALA followed by blue light. They reported a 70%

clearance, but a 20% recurrence of lesions at 3–4

months. Gold et al31

pretreated 12 patients with ALA

and then randomized them into two groups. Patients

were treated with either a 405–420 nm blue light or a

500–1200 nm IPL device monthly for 4 consecutive

months. Eleven patients completed the study. The

average reduction in SGH lesion count 3 months after

the last treatment was 55% for both the blue light- and

IPL-treated patients. Neither group had recurrence

of lesions during this period. Adverse effects were



experienced by three patients, and were limited to

erythema and one bulla.

Recently, Perrett et al28

investigated the treatment

of sebaceous hyperplasia in an immunosuppressed

patient. Organ transplant recipients are susceptible to

SGH, particularly on the face. Perrett et al pretreated

the forehead of a renal transplant recipient with MAL

and then treated it with IPL (633 nm, 80 mW/cm2,

and 75 J/cm2). This was repeated once 3 weeks later.

One month after the last treatment, all of the lesions

were either substantially reduced or decreased in size.

Six months from the initial treatment, the improve-

ment was sustained.

ACNE

Propionibacterium acnes and sebum secretion have been

shown to play major roles in acne production.As noted

previously, PpIX accumulates in pilosebaceous units. In

addition, it has been shown that exogenous ALA can

cause a preferential accumulation of protoporphyrin

in P. acnes.32

These observations were exploited by

Hongcharu et al13

in their seminal study to investigate

the effect of PDT on acne vulgaris. They treated 22

patients with mild to moderate acne of the back. Each

subject was treated at four sites with (a) ALA and red

light (500–700 nm at 150 J/cm2), (b) ALA alone, (c)

red light alone and (d) no treatment.The subjects were

randomized into two groups, with one half receiving

one treatment while the other half received all four.

The investigators measured changes in sebum excre-

tion rate, autofluorescence from bacteria in follicles,

protoporphyrin synthesis in pilosebaceous units, and

histological changes associated with treatment. They

discovered that after PDT treatment, porphyrin fluo-

rescence was suppressed in the bacteria, sebaceous

glands were damaged, and multiple PDT treatments

were associated with reduced sebum excretion rates. In

addition, they reported that inflammatory acne was

cleared for 10 weeks after a single treatment and 20

weeks after multiple treatments. However, a significant

side-effect profile ensued, with reports of acne-like fol-

liculitis, prominent hyperpigmentation, exfoliation and

crusting. None of the subjects developed permanent

scarring.

Since then, multiple studies have investigated

the role of PDT on acne vulgaris using pulsed

excimer–dye lasers,32

halogen light (600–700 nm),34

IPL,35

blue light,36,37

or PDL.38

Results have shown

that inflammatory acne vulgaris responds well to full-

face PDT treatments. Recently, a number of blinded,

randomized control trials with statistical analysis have

been published on this subject. In 2006,Wiegell et al38

investigated the effect of MAL–PDT versus no treat-

ment on moderate to severe acne vulgaris. Patients

were incubated with 3 hours of MAL under occlusion

and then with red light (37 J/cm2) on two occasions, 2

weeks apart. In their small trial, they found that 12

weeks after treatment the MAL–PDT group had a

68% reduction in lesions (p = 0.0023). However,

all patients experienced pain, pustular lesions, and

epithelial exfoliation.

Recently, in an effort to decrease some of the pho-

totoxicity that has long been associated with PDT,

various investigators have experimented with the

effects of decreasing the incubation time of topical

photosensitizers (from 3–4 hours to 30 minutes or

1 hour). Many report significant clearing of acne

lesions in these patients, with what does seem to be

fewer adverse effects after treatment. However,

long-term follow-up has been absent from many

of these reports, and is a needed area for future

study to confirm the sustainability of the reported

outcomes.36–41

HAIR REMOVAL

Multiple modalities are available for permanent laser

hair reduction. Some light and laser options include

ruby (694 nm), alexandrite (755 nm), diode (810 nm),

and neodymium : yttrium aluminum garnet (Nd:YAG)

(1064 nm) lasers, as well as IPL.42

However, PDT is

currently the only form of permanent hair removal

that functions independently of hair pigmentation. In a

pilot study in 1995, 12 patients were treated with

630 nm light, 3 hours after incubation with ALA. An

average of 40% hair loss was reported 6 months after

this treatment. Although this may offer utility in the

management of nonpigmented hair, further study is

required.43



SIDE-EFFECTS OF PDT

The major side-effect seen with PDT is cutaneous

photosensitivity after application of a topical photo-

sensitizer – what has been termed the ‘PDT effect’.

Protective clothing, barrier sunscreens, and rigorous

sun avoidance are necessary for 72 hours after therapy

to avoid sunburn. During the light delivery, patients

may experience burning, stinging, pruritus, or pain at

treatment sites.These sensations may represent direct

nerve stimulation and/or damage by reactive singlet

oxygen and released mediators. Discomfort is usually

tolerable, but premedication with anxiolytics may be

necessary in certain patients. For the majority, the dis-

comfort can be managed with conservative measures,

including the application of ice or the injection

of a local anesthetic. The local discomfort is not

prolonged. Localized edema, erythema, and a p’eau

d’orange appearance typically last for 1 day after treat-

ment, but may last for several days. Scarring is rare,

but possible. Transient hyperpigmentation and

hypopigmentation are the most common adverse

effects.

THE FUTURE

PDT has generated a great deal of interest in the

dermatology community over the past several years.

Short-contact, full-face ALA–PDT treatments with a

variety of lasers and light sources have been shown to

be a successful modality for photorejuvenation and the

treatment of associated AK, as well as sebaceous gland

disorders such as acne vulgaris. PDT is a proven

modality for the treatment of superficial skin growths:

AK, Bowen’s disease, and superficial basal cell carcino-

mas, as well as chronic inflammatory diseases such as

psoriasis.The treatments are relatively efficacious and

safe, but do have the downside of pain and photosensi-

tivity, even in cooler climates.

At present, it appears that PDT offers a safe and

controlled modality for targeted therapies of specific

skin conditions. A number of new applications are

currently being investigated and we look forward to

discovering new roles for this innovative dermatologi-

cal therapy. Looking forward, we hope to see more

double-blind randomized controlled trials to better

establish the safety and efficacy of PDT.

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2. Roelandts R. The history of phototherapy: Something

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3. Parrish JA, Fitzpatrick TB, Tanenbaum L, Pathak MA.

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7. Gold MH, Goldman MP. 5-Aminolevulinic acid photody-

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8. Daniell MD, Hill JS. A history of photodynamic therapy.

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9. Kennedy J, Pottier RH, Pross DC. Photodynamic therapy

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12. Bissonnette R, Lui H. Current status of photodynamic ther-

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ALA–photodynamic therapy for the treatment of acne

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emission spectra in vivo. Photochem Photobiol 1986;44:

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15. Morton CA. Photodynamic therapy in skin cancer. In:

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Skin. Philadelphia: Elsevier Saunders, 2005:515–26.

16. Szeimies RM,Abels C, Fritsch C.Wavelength dependency

of photodynamic effects after sensitization with 5-

aminolevulinic acid in vitro and in vivo. J Invest Dermatol

1995;105:672–7.

17. Gold MH. 5-aminolevulinic acid in photodynamic

therapy. An exciting future. VS Dermatology Review

2006;7:81–7.

18. Ruiz-Rodriguez R, Sanz-Sanchez T, Cordoba S. Photo-

dynamic photorejuvenation. Dermatol Surg 2002;28:742–4.

19. Alster TS, Tanzi EL, Welsh EC. Photorejuvenation of

facial skin with topical 20% 5-aminolevulinic acid and

intense pulsed light treatment: a split-face comparison

study. J Drugs Dermatol 2005;4:35–8.

20. Dover JS, Bhatia AC, Stewart B, Arndt KA. Topical 5-

aminolevulinic acid combined with intense pulsed light

in the treatment of photoaging. Arch Dermatol 2005;

141:1247–52.

21. Gold MH, Bradshaw VL, Boring MM, Bridges TM, Biron

JA. Split-face comparison of photodynamic therapy with

5-aminolevulinic acid and intense pulsed light versus

intense pulsed light alone for photodamage. Dermatol

Surg 2006;32:795–803.

22. Butler EG , McClellan SD, Ross EV. Split treatment of

photodamaged skin with KTP 532 nm laser with 10 mm

handpiece versus IPL: a cheek-to-cheek comparison.


23. Marmur ES, Phelps R, Goldberg DJ. Ultrastructural

changes seen after ALA–IPL photorejuvenation: a pilot

study. J Cosmet Laser Ther 2005;7:21–4.

24. Balin AK, Pratt LA. Physiologic consequences of human

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25. Schonermark MP, Schmidt C, Raulin C. Treatment of

sebaceous gland hyperplasia with pulsed dye laser. Lasers

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26. Divaris DXG, Kennedy JC, Poittier RH. Phototoxic dam-

age to sebaceous glands and hair follicles of mice after sys-

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with localized protoporphyrin fluorescence. Am J Pathol

1990;136:891–7.

27. Horio T, Horio O, Miyauchi-Hashimoto H, Ohnuki M,

Isei T. Photodynamic therapy of sebaceous hyperplasia

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28. Perrett CM, McGregor J, Barlow RJ, et al.Topical photo-

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31. Gold MH, Bradshaw VL, Boring MM, Bridges TM, Biron

JA.Treatment of sebaceous gland hyperplasia by photody-

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32. Ramsted S, Futsaether CM, Johnsson A. Porphyrin sensi-

tization and intracellular calcium changes in the prokary-

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1997;40:141–8.

33. Itoh Y, Ninomiya Y, Tajima S, Ishibashi A. Photodynamic

therapy of acne vulgaris with topical 5-aminolevulinic

acid.Arch Dermatol 2000;136:1093–5.

34. Itoh Y, Ninomiya Y, Tajima S, Ishibashi A. Photodynamic

therapy of acne vulgaris with topical delta-aminolevulinic

acid and incoherent light in Japanese patients. Br

J Dermatol 2001;144:575–9.

35. Goldman MP, Boyce SM. A single center study of

5-aminolevulinic acid and 417 nm photodynamic therapy

in the treatment of moderate to severe acne vulgaris.


36. Gold MH. A single-center open-label investigatory study

of photodynamic therapy in the treatment of moderate to

severe acne vulgaris with aminolevulinic acid topical

solution 20% and visible blue light. Abstract presented

at 61st Annual Meeting of the American Academy of

Dermatology, San Francisco, 2003.

37. Gold MH, Bradshaw VL, Boring MM, et al.The use of a

novel intense pulsed light and heat source and ALA–PDT


vulgaris. J Drugs Dermatol 2004;3:S14–18.

38. Alexiades-Armenakas M. Long-pulsed dye laser-medi-

ated photodynamic therapy combined with topical ther-

apy for mild to severe comedonal, inflammatory or cystic

acne. J Drugs Dermatol 2006;5:45–55.

39. Wiegell SR, Wulf HC. Photodynamic therapy of acne

vulgaris: a blinded, randomized, controlled trial. Br J

Dermatol 2006;154:969–76.

40. Taub A. Photodynamic therapy for the treatment of acne:

a pilot study. J Drugs Dermatol 2004;3:S10–14.

41. Santos MA, Belo VG, Santos G. Effectiveness of photody-

namic therapy with topical 5-aminolevulinic acid and

intense pulsed light versus intense pulsed light alone

in the treatment of acne vulgaris: comparative study.


42. Wanner M. Laser hair removal. Dermatol Ther 2005;18:

209–16.

43. Dierickx CC, Grossman MC. Laser hair removal. In:

Goldberg DJ, Rohrer TE, Dover JS, eds. Laser and Lights,

Vol 2. Philadelphia: Elsevier Saunders, 2005:61–76.



INTRODUCTION

The contemporary clinician is faced with both biologi-

cal and alloplastic materials to use as soft tissue fillers.

The clinician is eager to find an ideal implant, i.e., one

that will maintain its shape and consistency without

inciting an adverse host response. This ideal implant

has not yet been developed. Therefore, the clinician

must weigh the advantages and disadvantages of each

product on the market in order to achieve the most

harmonious result for a patient. Finally, the clinician

should seek to match the advantages and limitations of

each product with the desired result while becoming

personally comfortable with the use of a product.

BOTULINUM NEUROMODULATORS

In the 1980s, Allen Scott in San Francisco used botu-

linum neuromodulator in laboratory chick models for

selective weakening of treated muscles, and soon there-

after it was used for the management of strabismus.1

Botulinum neuromodulator is found in nature in seven

serotypes (A–G) defined by their specific biological

action in cleaving particular proteins involved in the

active transport of acetylcholine into the neurosynaptic

cleft responsible for muscle contraction (and other

autonomic functions).2,3

These naturally occurring pro-

teins were originally described as toxins causing the ill-

ness botulism, which is associated with the ingestion of

large amounts of foodstuffs contaminated with the bac-

terium Clostridium botulinum.They are better described,

with respect to their now widespread medical use, as

neuromodulators. Their distinct beneficial action is

selective weakening, relaxation, or paralysis of treated

muscles or muscle groups. By selective weakening of

certain hypertrophic muscle groups in the face and

neck, unwanted lines and facial expressions can be

suppressed or even eliminated.

While the B-serotype neuromodulator (Myobloc,

Solstice Neurosciences, San Francisco, CA) has demon-

strated benefit in the treatment of hyperfunctional

frown lines (HFL), its benefit under current formula-

tions is limited by the shorter duration of effect of the

product.4,5

Therefore, the A-serotype neuromodulator

is most optimal for the aesthetic practitioner. The A

serotype has demonstrated the longest duration of

effect (90–120 days) and least discomfort with injec-

tion. The most commonly used of the available A-

serotype neuromodulators is Botox (Allergan, Inc.,

Irvine, CA), which has a demonstrated safety and effi-

cacy record of over 15 years. Reloxin (Medicis Inc.,

Scottsdale,AZ), known as Dysport in Europe, is in cur-

rent phase III Food and Drug Administration (FDA)

clinical trials in the USA, and shows promise, as does

Purtox (Mentor Corp., Santa Barbara, CA), which is in

its early-phase FDA trials.

An understanding of how to use Botox relies on a

clear understanding of the facial muscular anatomy.

While many techniques and surface points of injection

have proven effective, it is clear that optimal response

with minimal effective dosages requires precise place-

ment in the selected muscle or muscle group (Fig. 16.1).

The use of Botox on the upper face has been demon-

strated in controlled large-population anatomical stud-

ies.6

Interest in lower facial applications has reinforced

16. Adjunctive techniques I: the bioscience

of the use of botulinum toxins and fillers

for non-surgical facial rejuvenation

Kristin Egan and Corey S Maas


the need for a fundamental understanding of this muscular

anatomy.7

It is clear, however, that, due to diffusion

effects and the relative safety of Botox, the variability in

points of injection and dosages has not significantly

reduced the product’s overall satisfactory clinical results.

In our opinion, required dosages for a given anatomical

area can be reduced by precise localization and direct

injection into the targeted muscle or muscle groups.

It is imperative that one keep in mind not only the

specific muscle locations when providing neuromodula-

tor treatment, but also the functional interrelationships

of the muscle action. Many of these act as antagonist–

protagonists in the position of the brow. The use of

Botox in general has evolved with experienced and

thoughtful injectors from a simple wrinkle treatment to

a means of reshaping, contouring, and softening the

facial features associated with aging and the stigmata of

the frowning, angry or worried facial form.

Botox is frequently used to specifically target differ-

ent muscular units. In the glabellar region, targeting of

the procerus and corrugator muscles is used to elimi-

nate furrowing along the radix and medial eyebrow

region.The lateral orbital region, which is commonly

referred to as the ‘crow’s feet’, is also a region in which

Botox may be of use to target the orbicularis oculi mus-

cle and reshape the upper face.The use of Botox in the

forehead must be conservative in order to balance the

risk of brow ptosis by targeting the only brow elevator,

the frontalis muscle. Perioral lip lines have also been

treated with sparing amounts of Botox to suppress the

pursing effect of the orbicularis oris muscle. One must

be careful not to compromise oral competence as a

result of this treatment. Botox injection into the

depressor anguli oris muscle can target marionette

lines, and its use for contraction of the mentalis muscle

can alleviate complaints of a dimpled chin appearance,

but one must be careful to avoid the lower lip depres-

sors. Platysmal banding in the neck due to overactive

platysmal muscle action can be treated using Botox.

However, this works best for younger patients with

good skin elasticity or postoperative residual bands.8

This facial characteristic may ultimately only be treated

optimally with surgical intervention.

The use of botulinum toxin type A and laser resur-

facing has been studied recently due to the prolifera-

tion of nonsurgical treatments for the aging face and

the desire to perform more than one treatment in one

visit. It has been demonstrated that the use of Botox in

conjunction with laser resurfacing results in improved

outcomes in the periorbital region.9

Other areas of the

face have also been studied and have been shown to

have less rhytids after Botox and laser than those areas

treated with laser alone, and these results were clini-

cally most significant in the crow’s feet region.10

It has

also been shown that the use of Botox as an adjunctive

treatment will prolong the beneficial results of laser

resurfacing and should therefore be offered as an

option to patients wishing to have longer-lasting

elimination of rhytids.11

It is safe to use laser resurfac-

ing after treatment with Botox, as this will have no

effect on the efficacy of the Botox injection or other

apparent untoward effects.12


Fig.16.1 The glabellar complex as demonstrated before and after injection of botulinum toxin.


HISTORICAL PERSPECTIVE

The search for an ideal product to be used for soft

tissue augmentation has been ongoing with varying

degrees of success since the end of the 19th century.

Autologous fat was first reported as a soft tissue filler

by Neuber in 1893.13

Paraffin was later used, but with

significant drawbacks.13,14

The ensuing years brought

the use of vegetable oils, mineral oil, lanolin, and

beeswax; all demonstrating the problems that continue

to be associated with fillers in use today, namely

chronic inflammation and migration.15–18

Purified

bovine dermal collagen was first developed in an

injectable form in 1977 by Knapp et al.19

In early

trials, the most common complications seen were

cellulitis, urticaria, and hyperpigmentation of the

skin making it superior to its predecessors.19

Teflon, polytetrafluoroethylene paste, was initially

thought to be a useful soft tissue filler. However, its

consistency and injectability limit its main commercial

use today to vocal cord augmentation procedures.20

It is reasonable to divide soft tissue fillers into the

biologicals and the nonbiologicals.We will first discuss

the biologicals, both tissue-derived and synthetic.

Finally, we will discuss the nonbiologicals, i.e., fillers

not based on animal tissue. Table 16.1 is offered as a

reference to help guide clinicians in the selection of a

soft tissue filler.

BIOLOGICAL MATERIALS USED AS

INJECTABLE IMPLANTS

The use of biological materials for injection is thought

to be advantageous in that the inflammatory response

should be less for a substance that is of nonimmuno-

genic biological origin. However, cross-reactivity has

not been eliminated altogether, and although biologi-

cal fillers do result in less fibrosis and contraction

around the injection site, problems still exist. The

most common side-effect seen with the use of soft tis-

sue fillers is the localized reaction to the injection or

implantation. Swelling, redness, and pain can all be

treated with conservative measures. Allergies and

delayed hypersensitivity responses are more serious

complications, and indeed preclude the further use of

the material.

Collagen

Collagen was the first material to be approved by the

FDA for used as an injectable soft tissue filler, in 1981.15

Many derivatives are available today, including Zyderm I

(35 mg/dl), Zyderm II (65 mg/dl), and Zyplast

(Collagen Corp., Palo Alto, CA). Cosmoderm and

Cosmoplast (Inamed Corp., Santa Barbara, CA) differ

from Zyderm and Zyplast only in that they are

injectable human collagen products derived from a sin-

gle cell line source. Zyderm I was the first nonautolo-

gous agent to be approved for use as a soft tissue filler in

the USA, in 1981.21

Zyderm II was soon developed as a

more concentrated form.These substances work on the

basis of low-grade focal inflammation and are of a for-

giving nature.They are easy to inject, and precise injec-

tion technique is not very important. Zyderm is derived

from bovine dermal collagen, with 95% type I and 5%

type III collagen.The processing of Zyderm removes

the telopeptide regions of the molecule without dis-

rupting the natural helical structure. However, 3–3.5%

of the population still demonstrate a hypersensitivity to

the substance, and after one negative skin test, 1–5 % of

patients will still show an allergic reaction when the

material is placed in the face.22

Zyplast is crosslinked by the addition of glutaralde-

hyde, which lessens the immune response to it and also

serves to increase resistance to bacterial collagenase.

Zyderm injections will provide cosmetic results for

2–3 months, at which time repeat injections are

needed. Zyplast provides longer results (on average

2–4 months) due to its crosslinking, but eventually

The bioscience of the use of botulinum toxins and fillers for non-surgical facial rejuvenation 183

Table 16.1 Soft tissue fillers

Synthesized Synthetic

Biological filler bioactive non-resorbable

materials fillers polymers

Bovine collagen Sculptra Artecoll

Recombinant Reviderm intra Silicone

human collagen

Juvederm Radiesse Ultrasoft

Hyaluronic acid Softform

Dermal matrices Advanta,

Dermalive,

Dermadeep


repeat injections are also necessary. Zyderm and

Zyplast have to be injected intradermally. Zyderm is

infiltrated into the papillary dermis, whereas Zyplast is

preferably placed into the midreticular or deep reticu-

lar dermis at the dermal–subcutaneous interface.

Zyplast should not be injected into the superficial pap-

illary dermis or in areas of thin skin, because it forms

beads on placement.23

Hyaluronic acid

Hyaluronic acid is a biopolymer of glycosaminoglycan

chains, which coil on themselves resulting in an elastic

and viscous matrix. It is found naturally in the dermis

and has a high affinity for water, thereby serving to

hydrate and plump the skin.24

The loss of hyaluronic acid

with age leads to dermal dehydration and the formation

of rhytids.25

Crosslinking can lengthen the half-life of

hyaluronic acid, but cannot eliminate its degradation.

Products clinically available include Hyalform, Hyalform

Plus and Hyalform Fine Line (Biomatrix, Inc.,

Ridgefield, NJ), Restylane (Q-Med, Uppsala, Sweden),

and Captique (Genzyme, Ridgefield, NJ), and other

forms, such as Juvederm (Allergan, Irvine, CA), are

under clinical trail in the USA. Q-Med is also responsi-

ble for Restylane Fine Line and Perlane. Perlane is

designed for subcutaneous injection and is primarily

used for volume replacement. It is a larger particle than

that found in Restylane, and therefore has a longer

duration.

While Juvederm is a pure hyaluronic acid form that is

rapidly absorbed, Hyalform is a crosslinked xenogenic

variety derived from rooster combs, which was submit-

ted for FDA approval as an equivalent product to

Restylane.The latter is only partially crosslinked and is

processed from a streptococcal fermentation.24

Neither

material requires skin testing. Restylane, not being

derived from an animal source, has a lower risk of

immune reaction. Both forms are reabsorbed, albeit at a

slower rated than the collagen products. It has been

reported that effects last up to 6 months.26

Hylaform is

less viscous, and this may decrease the duration of its

effect to 2–4 months, although no side-by-side trials

have been published.

Hylaform is a modified form of hyaluronan, a natu-

rally occurring substance found in human skin and

throughout the body. Since Hylaform is based on

natural hyaluronan, the human body accepts it as its

own. Hylaform also mimics the hydrating and lifting

effect of hyaluronan, which keeps the skin hydrated and

elastic. In side-by-side comparison with Restylane,

Hyalform showed a higher incidence of skin reaction.26

Hyalform also behaves as a stronger hydrogel than

Restylane and contains a lower amount of crosslinked

hyaluronic acid. Restylane can contain up to four times

as much protein, from bacterial fermentation, as

Hyalform for the same volume. Finally, hyaluronan

derived from rooster combs has been in use longer than

that derived from streptococci, and has demonstrated

its reliability and safety.

A randomized study of 138 patients comparing

Restylane and Zyplast for the correction of nasolabial

folds demonstrated that a more durable aesthetic

improvement was found with Restylane.27

Less injection

volume was required with Restylane, which was also

superior to Zyplast in retaining its shape. A comparison

of Restylane with and without the addition of Botox

demonstrated that glabellar rhytides responded better to

the combination of Restylane and Botox.28

Those

patients who present with deep vertical glabellar lines at

rest may not be able to eliminate those lines with the use

of Botox alone. Restylane can serve to fill the resting

lines, and the addition of Botox prevents the deforma-

tion of the filler residing in the dermis, thereby perform-

ing a protective function. Restylane is also useful as a soft

tissue filler for microchelia (Fig. 16.2).

Captique is a filler that utilizes a recombinant form

of hyaluronic acid that lowers the probability of

immunological reactions.The profiles of this filler are

much the same as those of Hyalform, with a duration

of 2–4 months and a similar injection and viscosity

profile.

Materials that are resorbable by the body are

less likely to provoke a longstanding immunological

response, because of their transient nature. However,

substances that are derived from nonautologous

sources have the potential to evoke cross-reactivity.

Restylane and Hylaform are newer materials that are

beginning to undergo long-term studies, which are

beginning to show side-effects.A study of 709 patients

over 4 years showed positive skin tests in those who

developed delayed skin reactions to these materials.

The manufacturer does not recommend skin testing

for these materials – but these reports may suggest



otherwise.29

Case reports have also shown the potential

for granuloma formation with the use of hyaluronic

acid derivatives.30

Positive skin tests have demon-

strated chronic inflammatory reactions at up to 11

months and serum immunoglobulin G (IgG) and IgE

antibodies to hyaluronic acid.32

Of course, these

aesthetic complications must be fully addressed with

the patient before any procedure is performed.

Dermal matrices

The search for soft tissue fillers free of antigenicity

has led to the development of Alloderm and Cymetra

(LifeCell Corp., Branchburg, NJ).Alloderm is processed

from cadaveric skin, preserving the basement mem-

brane and dermal collagen matrix. After the fibroblasts

have been extracted, the material is cryoprotected,

which enables it to be freeze-dried in a two-step proce-

dure.Alloderm is screened and monitored for bacterial

contamination before it is shipped to the physician. It is

supplied in sheets of differing sizes and thicknesses,

which must be rehydrated by the physician before use.

The sizing of this material makes it ideal for repairing

large tissue defects. Skin testing is not necessary,

because it is an acellular graft. It is also less likely to

develop secondary infection. However, if infection does

occur, it is not necessary to remove the implant, only to

treat the infection.22

Alloderm does not appear to last as

long or be as consistent as originally described, which,

along with its high cost, has decreased its use and popu-

larity.The requirement for a surgical procedure has also

limited its use. Zyplast was studied in direct comparison

with Alloderm with follow-up at 1 year, by Sclafani

et al.32

Superior results were seen with Alloderm which

stabilized in resorption at 6 months, while Zyplast was

progressively absorbed.

Cymetra is a micronized injection of Alloderm tissue.

It is created by homogenizing an Alloderm sheet cut into

strips. In a study of 44 patients involving the use of

Cymetra and Zyplast to fill upper lip lines, there was a

statistically significant improvement at 1 year in lip

appearance among those randomized to receive

Cymetra. Some reports suggest that Cymetra does not

reabsorb as Zyplast is observed to do, and therefore

repeated treatments provide an additive effect and are

more effective.33

Cymetra carries an increased incidence

of inflammatory reactions and has not been shown to last

longer than Zyplast. It also requires mixing into a thick

paste, usually with 1% or 2% lidocaine. This thick

mixture can be difficult to inject. Due to the lack of


Fig.16.2 Restylane used as a soft tissue filler for lip augmentation.


long-term results and the increased cost, Cymetra is not

used as frequently as other soft tissue fillers.

Small-intestinal submucosa, marketed as Oasis,

Surgisis, or Stratasis, is a sterile acellular graft material

extracted from the small intestine of pigs. Its main uses

continue to be for nasal reconstructive surgery, but

increasing experience may broaden its applications.

Isolagen (Isolagen Tech., Metuchen, NJ) is currently

under FDA investigation. It consists of injectable

fibroblasts derived from an autologous source and

cultured for 4–6 weeks. Skin is harvested from the

preauricular region in a 3 mm punch biopsy.34

Repeat

injections, most commonly three, are required, spaced

2 weeks apart. A 6-month study by Watson et al35

showed increased thickness and density of the postau-

ricular dermal collagen and no inflammatory reaction.

Due to the viability of the fibroblasts, Isolagen must be

shipped, processed, and injected within 24 hours.

However, it theoretically has the advantage of low

immunoreactivity, as with the other human deriva-

tives. A significant drawback is that patients must also

be willing to wait up to 18 months to see results, as the

fibroblasts must first produce new collagen.

SYNTHESIZED BIOACTIVE FILLERS

The search for the ideal soft tissue fillers has led to the

development of materials that do not mimic collagen

but rather serve to increase volume for a longer period

of time due to their preformed microsphere shapes.

Sculptra (Biotech Industry, SA, Luxembourg) is a

powder of poly-L-lactic acid microspheres ranging

from 2 to 50 µm. Studies comparing the various soft

tissue fillers have shown the microspheres of Sculptra

to be histologically degraded at 9 months. Sculptra has

only been FDA-approved for the treatment of HIV

lipodystrophy, and provokes an intense inflammatory

reaction leading to a fibroblastic response resulting in

increased appearance of the tissue.The complications

reported include draining granulomas, and (like other

fillers) it must be injected subcutaneously.

Reviderm intra (Medical International, Netherlands),

available in Europe, is a suspension of 2.5% dextran

microspheres of 40 µm in 2.0% hyaluronic acid.

Radiesse (formerly Radiance FN) (Bioform Inc.,

Franksville, WI) is a suspension of 30% calcium

hydroxyapatite (similar to the composition of bone)

microspheres ranging in size from 25 to 40 µm in a

carboxymethylcellulose gel. The microspheres of

Reviderm produced the greatest amount of granula-

tion tissue, but were also disintegrated at 9 months.

Radiesse microspheres were gone at 9 months, but

they stimulated almost no foreign body reaction.36

Few macrophages were visualized surrounding the

microspheres of Radiesse, suggesting that they are

degraded by enzymatic processes rather than cellular

one. Radiesse is not recommended for use in lip aug-

mentation, as the microspheres will be compressed

into strands during the act of mastication. Radiesse is a

thick paste, which can be difficult to inject and must be

injected only in deep dermis. It is used in the

nasolabial folds, but we caution use in the lips, which is

also the policy of the manufacturer. It has an increased

incidence of nodule formation, which can only be

dealt with by surgical excision.

SYNTHETIC NONRESORBABLE

POLYMERS

Materials that are foreign to the human body have also

been used in the development of soft tissue fillers in

both injectable and implantable forms.

Injectable

Artecoll (Artes Medical Inc., San Diego, CA) is a

suspension of 20% microspheres 40 µm in diameter

made of polymethylmethacrylate (PMMA) in 3.5%

bovine collagen solution.Artecoll works by microgranu-

loma formation, which may not be controllable. This

product produces immediate correction with collagen

and also permanent replacement with new collagen pro-

duced as part of the inflammatory response.22

Artecoll,

unlike the other microspheres, does not become reab-

sorbed, and histologically new collagen deposits are

visible at 1 month.36

A minimal immunogenic response

has been observed due to the fact that the telopeptides

are removed from the collagen.As with other xenogenic

injectables, skin testing is required before use.

The smooth surface of the microsphere prevents a

foreign body reaction, and the size prevents migration



and phagocytosis.37

It should not be used in areas of

fine skin, as the implants may be more visible, and

should be avoided in those patients prone to keloids, as

any foreign material may serve to increase the incidence

of keloids. However, Artecoll demonstrates a much

lower incidence of immunological response, 0.06%, as

compared with Zyderm, which has an incidence of

3%.36

Migration has only been observed when the

material is injected into the dermis in trials with guinea

pigs, and has not been observed with correct placement

of the material.38

Artes Medical may reformulate the

product in a US version with hyaluronic acid to meet

FDA requirements. All injectable filler materials may

lead to overexpression of the host’s foreign body-type

immunological reaction.This may, in rare cases, lead to

the formation of a granuloma.

The combination of materials is foreshadowed

in the development of Dermalive and Dermadeep

(Dermatech, Paris, France). In Europe, 30 or more

synthetic polymers are available for use in general,

although this may vary somewhat by country. Examples

of such polymers include Dermalive, and Dermadeep,

which are combinations of pure hyaluronic acid (40%

and 60%, respectively) and an acrylic hydrogel. The

hyaluronic acid is used as a carrier for the acrylic poly-

mer.They have been developed in response to the need

for repeat injections when using such materials as

pure hyaluronic acid and collagen. The tolerance of

Dermalive is excellent and it has been supplemented

with injections of Juvederm or Restylane for fine line

and superficial defects.39

A 3-year study of this combi-

nation therapy in 455 patients demonstrates an 88%

patient satisfaction rate with minimal side effects.39

Silicone, much maligned due to its history in breast

augmentation, is another synthetic injectable. Its

use has been associated with the development of

connective tissue ingrowth and granulomas from

macrophages and foreign body cells (Fig. 16.3).40

This

is more commonly seen in patients with very lax

skin, which facilitates the migration of the silicone,

and with the substitution of cheaper, non-medical-

grade silicone fluids used by nonprofessionals.36

When used as silicone fluid, the material is injected

via the microdroplet technique. In the rare case of

siliconoma development, the use of corticosteroids

has proven helpful, but this is rarely a completely sat-

isfactory treatment.41

Late-term granulomas are not

uncommon. As a result, we do not recommend this

material.

Implantable

Implantable expanded polytetrafluoroethylene (e-

PTFE) (WL Gore and Assoc., Flagstaff, AZ) has been

used in the field of vascular surgery for over 30 years,

demonstrating its safety and reliability.42

Tissue

ingrowth is marginal into the material, but when it is

shaped into a tube, longitudinal growth occurs. This

serves to strengthen the filler and secure it to the site

of implantation.43

Ultrasoft is a thinner, softer form of

the tubular form of implantable expanded polytetra-

fluoroethylene (Fig. 16.4).

The tubular form was originally marketed under the

name SoftForm (Collagen Corp., Palo Alto, CA), and

was used as soft tissue filler for lip augmentation.

There still exists a risk of extrusion or exposure of the

ends of the material at the entrance wound where the

implant is delivered. Softform showed wall stiffening

due to the abundance of ePTFE creating an accordion

effect.The risk of extrusion at the insertion sites cre-

ates a potential source of infection. If complications do

arise, the implant is always removable. Due to the

higher content of ePTFE, Softform shortens and hard-

ens with time. This can create an ‘accordion effect’.

Ultrasoft, with its thinner walls, has addressed this

issue, with early success being reported.


Fig.16.3 Granuloma and foreign body reaction after

injection of silicone.


Advanta (Atrium Medical Corp., Hudson, NH) is

a dual-porosity implant developed to provide softer

palpability, less migration, and reduced shrinkage.The

outer core measures 40 µm and the inner 100 µm,

with the inner core being exposed to the surrounding

tissue. A study comparing Softform with Advanta

demonstrated neovascularization and cellular integra-

tion into the interstices of the Advanta implant, while

the Softform implant demonstrated a cellular capsule,

more inflammatory cells, and fewer vascular elements

within the devices.44

Advanta is designed for use in the

nasolabial folds and for lip augmentation.

TECHNIQUES

When considering injectables, there are basically three

techniques used to deliver material to the deep dermis

or subcutaneous level: linear threading, serial puncture,

and droplet. Linear threading is a technique by which an

agent is delivered in a uniform fashion while the needle

is slowly withdrawn from the tissue. It is particularly

effective when performing lip augmentation along the

mucocutaneous border.The serial puncture technique is

used to deliver small aliquots of filler at multiple spots

to achieve even distribution over a two-dimensional

area. Finally, the droplet technique is used in a manner

similar to that in linear threading. However, instead of

an even distribution of filler as the needle is withdrawn,

microdroplets of filler are delivered into the tissue by

gentle pumping on the syringe as the needle is with-

drawn.The droplet technique has been advocated for

use when injecting silicone. The depth of injection,

however, is dependent on the injectable material being

used. Most clinicians prefer the serial injection tech-

nique for use in fine lines and the lips.The other options

include the microdroplet technique or surgical implan-

tation in the subcutaneous plane.

CONCLUSIONS

Many patients who present to their physicians with

complaints of an aging face or cosmetic deformities are

eager to avoid surgical intervention. As such, they are

willing to use newly introduced minimally invasive

options for their desired corrections.Today, there is a

myriad of injectable and implantable soft tissue augmen-

tation options at the experienced clinician’s disposal. A

concern with the use of permanent filler is the potential

for migration to other areas outside of the injection site,

which can lead to potential deformities.The choice of


Fig.16.4 Ultrasoft used for lip augmentation.


which product to use can be based on a number of

factors, including the desires of the patient, the cost to

the patient, and the experience of the clinician. Caution

must be exercised, however, when considering the use

of soft tissue fillers that have been newly introduced to

the market and have not yet undergone long-term

observation and study.With more knowledge and expe-

rience, one will be better able to tailor the use of specific

materials to the particular desires of each patient.

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18. Newcomer VD, Graham JH, Schaffert RR, Kaplan L.

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lipids.AMA Arch Dermatol 1956;73:361–72.

19. Knapp TR, Kaplan EN, Daniels JR. Injectable collagen

for soft tissue augmentation. Plast Reconstr Surg 1977;

60:398–405.

20. Landman MD, Strahan RW,Ward PH. Chin augmentation

with polytef paste injection. Arch Otolaryngol 1972;95:

72–5.

21. Cooperman LS, Mackinnon V, Bechler G, Pharriss BB.

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22. Ashinoff R. Overview: soft tissue augmentation. Clin

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23. Skouge JW DR. Soft tissue augmentation with injectable

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24. Krauss MC. Recent advances in soft tissue augmentation.


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26. Lowe NJ, Maxwell CA, Lowe P, Duick MG, Shah K.

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30. Fernandez-Acenero MJ, Zamora E, Borbujo J.

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granulomatous reaction after cosmetic dermal silicone

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2002;4:92–7.



INTRODUCTION

Constantly evolving technology has given cosmetic

physicians and surgeons an ever-increasing armamen-

tarium with which to deliver more effective treat-

ments with minimal or no downtime. Combining a

variety of therapeutic options can yield an enhanced

effect that is more than the sum of its individual

parts. Understanding the balance of facial muscula-

ture is essential for facial rejuvenation and facial

reshaping utilizing botulinum toxin. The concept of

facial muscle relaxation and balance is the foundation

on which further rejuvenation with fillers can

be built. The expanding menu of fillers gives us an

enlarging palate of materials for facial filling,

volumizing, and rhytid ablation (Fig. 17.1).

BOTULINUM TOXIN TYPE A

DILUTION AND INJECTION

TECHNIQUE

Botulinum toxin type A (Botox and Botox Cosmetic)

binds to the nerve endplate and blocks the release of

acetylcholine, decreasing the strength of muscle con-

traction and reducing dynamic rhytidosis.1,2

This bond is

permanent, and acetylcholine release begins again when

the nerve sprouts a new endplate. One hundred units of

Botox is packaged as a powder.This purified protein is

reconstituted in sterile saline, typically in 1, 2, or 4 ml

to give the desired dose in 0.1ml aliquots.3

Different

vials can be mixed for different strengths for different

muscles (Figure 17.1). During the actual mixing of

Botox, the vacuum seal must be broken with two needle

punctures before instilling the saline to avoid an overex-

uberant mixing and frothing of the Botox, which can

affect potency.The saline should be added slowly, angled

against the side of the vial, avoiding frothing of the mix-

ture. Although it is claimed that the use of preserved

saline diminishes discomfort during injection (there is

less of a burning sensation) and that it lengthens the

time that reconstituted refrigerated Botox can last, we

continue to use non-preserved saline for reconstituting

Botox.We feel that it may retain its potency for a longer

period of time.4When storing reconstituted Botox, it

should be refrigerated and not frozen.Adequate dosage

for each muscle group is key.While an insufficient dose

will yield an insufficient result, overtreating is also not a

desired cosmetic result. Because the patient may not

begin to notice the clinical effect for at least 3–5 days,

and the full effect may not be evident for 7–10 days, we

request a revisit for a dose adjustment in 1–2 weeks fol-

lowing the initial treatment session.

After cleansing the injection sites with alcohol (there

is some discussion about alcohol reducing the effect

of botulinum toxin), we prefer to apply a topical

lidocaine/tetracaine anesthetic cream, Photocaine

(Universal Pharmacy, Salt Lake City, Utah), for 15–20

minutes. Further vasoconstriction is encouraged by

17. Adjunctive techniques II: clinical aspects

of the combined use of botulinum toxins

and fillers for non-surgical facial rejuvenation

Stephen Bosniak, Marian Cantisano-Zilkha, Baljeet K Purewal,

and Ioannis P Glavas


application of iced compresses; we have not noted any

rebound effect after using this technique. In addition, to

avoid bruising, patients are given Arnica Montana C5

pellets (Boison, Newton Square, PA) sublingually

immediately preceding their injections and asked to

continue taking them four times a day for 2–3 days.

Injections are given subcutaneously and tangentially

when possible. Because of the diffusion characteristics

of botulinum toxin, it is not necessary to inject into the

muscle plane. Avoiding deep injections will avoid

hematoma formation with accompanying bruising (and

patient perception that this is an invasive procedure).

Following the injections, direct pressure is applied

until there is no sign of oozing from the injection sites.

We follow a general guideline of doses that we have

found to work safely and effectively for the different

anatomical areas of the face (Table 17.1).While dosing

may vary slightly on an individual basis, this may be

adjusted on subsequent follow-up visits.

Dysport is also a type A botulinum toxin, but has a

more marked spreading effect; these diffusion charac-

teristics may affect the clinical outcome and the dura-

tion of the effect, but the exact differences between

Botox™ and Dysport has yet to be determined. It is

currently being used in Europe and South America,

and will be available in the USA probably in 2007 or

2008, under the name Reloxan. Approximately 3–5

units of Dysport (Reloxan) are equivalent to one unit

of Botox. Like Botox, Dysport (Reloxan) has to be

reconstituted with sterile saline.

OVERVIEW OF FILLERS AND

INJECTION TECHNIQUE

Due to the wide variety of injectable fillers available

today, when choosing the appropriate product, it is

important to match the product with the tissue.


Fig.17.1 Facial asymmetries can be corrected with an intimate knowledge of the balance of facial musculature.Botulinum

toxin can be used to weaken the overactive muscles, allowing opposing musculature to function normally, thereby creating a

balance. (a) This patient had a hemifacial spasm following Bell’s palsy. (b) Facial symmetry was achieved by understanding the

balance of the facial musculature and injecting the appropriate muscles with botulinum toxin.

ba


The evolution of safer, longer-lasting and more conve-

nient, readily available materials for adding volume to

facial structures and filling in static facial lines and

furrows has added a new dimension to noninvasive

facial rejuvenation.

An ideal filler should meet a number of require-

ments. It has to be long-lasting, nontoxic, fully bio-

compatible, nonimmunogenic, nonmigratory, and

inexpensive, with the ability to be stored, shaped,

removed, and sterilized easily.5While we have not yet

achieved filler nirvana, the non-animal-derived stabi-

lized hyaluronic acid products are the current state of

the art, fulfilling many of our criteria.6

Fillers can be classified as nonpermanent or perma-

nent; biodegradable versus nonbiodegradable; animal-

based versus non-animal-based; and autologous versus

nonautologous.

While autologous fat is historically the oldest avail-

able filler, bovine collagen in the form of Zyderm I,

Zyderm II, and Zyplast was the most frequently used

substance until hyaluronic acid products were

approved by the US Food and Drug Administration

(FDA) in 2003.7The hyaluronic acids can be derived

from avian or bacterial sources; each product has its

own specific characteristics8 (Table 17.2). Hyaluronic

acid must be crosslinked through chemical alteration

to stabilize the molecule.

While more crosslinking may increase the longevity

of the clinical effect, it is difficult to compare the clin-

ical efficacy of different products based on the amount

of crosslinking alone. Excessive crosslinking may

impair the ability of the hyaluronic acid molecules to

retain and attract water molecules and secondarily

limit the ultimate clinical effect. So it remains to be

seen which product will yield the best possible clinical

outcome. More than likely, the multitude of available

products will eventually have their own specific goals

for indication of use.

Gel particle size is, however, relevant for compari-

son of Q-Med Sweden hyaluronic acid products (Table

17.3).The more viscous products have a larger parti-

cle size.This is important in considering the area and

depth of implantation of the product. Juvederm is

composed of blended random-sized particles, which

may conceivably affect its flow characteristics.

INJECTION TECHNIQUES

There are four different implantation techniques that

are generally utilized: linear threading, serial punc-

ture, fanning, and cross-hatching. It is important to

remember that for each technique, the more slowly

the infection is performed, the less discomfort is

caused to the patient and bruising is reduced.

Serial puncture is technically the easiest method,

since the needle tip does not move during injection.

The needle enters the skin to the desired depth, a

small aliquot of filler is deposited, and the needle is

withdrawn.9

The linear threading technique consists of holding

the needle parallel to the length of the wrinkle or fold

to be treated, piercing the skin, and advancing the

needle and injecting in either a retrograde or antero-

grade fashion, making sure to stop injecting prior to

needle withdrawal.9

The fanning and cross-hatching techniques are varia-

tions of the linear threading technique. These tech-

niques can be implemented in areas where a larger

volume of filler is needed or a multicontoured area is

being filled. Even though theoretically the fanning

technique should yield less bruising, we have found

that this is not necessarily true. In our experience,

applying the fanning technique via multiple puncture

sites has produced less bruising.

Regardless of the product to be used, each patient is

prepped with alcohol and treated while sitting in the

upright position.The patient is given three sublingual

Arnica C5 pellets and asked to continue taking them

four times daily for 3 days.We use topical anesthetic

(Photocaine) on every patient and rarely use regional

blocks.

Clinical aspects of the combined use of botulinum toxins and fillers 193

Table 17.1 Botox dosages

Anatomical region Dose (units)

Forehead 10–15

Glabellar 20–60

Crow’s feet and lateral brow depressors 15–20

Lower eyelids (pretarsal) 2

Upper lip 1–2

Depressor angulii oris 2–5

Platysmal bands 20–50



Table 17.2 Hyaluronic acid products

Approved indication FDA Injection

Product Sourcea

in USA approval Duration needle

Restylane Bacterial fermentation For the correction of moderate to December 6–8 30-gauge

NASHA technology severe facial wrinkles and folds 2003 months

Perlane Bacterial Not yet FDA-approved. Designed Not yet in 9–12 27-gauge

fermentation for shaping facial contours (e.g., in the USA months

NASHA the cheeks and chin), correcting

technology deep folds, and for lip augmentation

Fine Lines Bacterial fermentation Not yet FDA-approved. Designed Not yet in 4–6 32-gauge

(Touch) NASHA technology for correcting thin superficial lines, the USA months

forehead lines, and perioral rhytids

Restylane Bacterial Not yet FDA-approved. Designed Not yet in 9–18 18-gauge

SubQ fermentation for deep subcutaneous the USA months cannula

NASHA technology or supraperiostal injections

Captique Produced by For the correction of moderate to November 4–6

bacterial fermentation severe facial wrinkles and folds 2004 months

Juvederm Produced by For the correction of moderate to June 2006 9–12 27-gauge

Ultra plus bacterial fermentation severe facial wrinkles and folds months

Juvederm Produced by For the correction of moderate to June 2006 6–8 30-gauge

Ultra bacterial fermentation severe facial wrinkles and folds months

Cosmoderm Bioengineered For superficial lines: perioral, March 3–5 30-gauge

human collagen periocular, glabellar 2003 months

Cosmoplast Bioengineered human For improvement of deep folds and March 3–5 30-gauge

collagen crosslinked wrinkles: nasolabial, vermilion 2003 months

with glutaraldehyde border, marionette lines

Zyderm Highly purified For fine lines: perioral, 1981 3–5 30-gauge

reconstituted periocular, glabellar months

bovine collagen

Zyplast Highly purified For improvement of deep folds 1985 3–5 30-gauge

reconstituted bovine and wrinkles: nasolabial, months

collagen crosslinked vermilion border, marionette

with glutaraldehyde lines

Sculptra Poly-L-lactic acid For the restoration and/or the August 1–2 26-gauge

correction of facial fat loss 2004 years

(lipoatrophy) in patients with HIV

Radiesse Calcium Long-lasting correction of moderate December 1–2 27-gauge

hydroxyapatite to severe facial wrinkles and folds 2006 years

microspheres such as nasolabial folds. Radiesse

suspended in also received a second FDA approval

an aqueous gel for the long-lasting correction of

lipoatrophy in patients with HIV

aNASHA, nonanimal stabilized hyaluronic acid.


Certain products require preparation beforehand.

For example, Sculptra (poly-L-lactic acid) must be

reconstituted the day before it is used and shaken very

well before use. Each bottle contains 0.15 g of powder

that has to be mixed thoroughly to create a suspension.

Seven milliliters of diluent (5 ml sterile water and 2 ml

lidocaine) provide a sufficiently liquid suspension for

easy injection and decrease the incidence of granuloma

formation.The sterile water should be added first, and

one should wait at least 2 hours before shaking the

bottle. Preferably, the suspension should sit overnight

and then, prior to injection, 1–2 ml of lidocaine may

be added. It is important to shake the suspension well

before use to decrease the incidence of granuloma for-

mation and to avoid frequent clogging of the needle. If

the suspension is not used immediately after being

shaken, it may clog the needle and require frequent

needle changing. Sculptra, injected in a retrograde

fashion, is useful for filling in broad areas of facial

depression. Because the amount of correction

improves with time, inciting a mild subcutaneous

inflammatory response and secondary collagen pro-

duction, a gradual filling in the contour defect is rec-

ommended, avoiding overcorrection.At each injection

session, the appearance of the final result is approxi-

mated. The patient is informed of a period of disap-

pointment over the following several weeks when the

diluent is absorbed and before secondary filling is

observed. Repeat injections are typically given at

6-week intervals. Injecting 0.1 ml aliquots deeply and

then massaging the tissue well is essential to avoid

papule formation and to achieve an excellent result.

Because Sculptra is a suspension, the ‘feel’ while

injecting it is different from the hyaluronic acid gels

and the ‘paste’ of hydroxyapatite.

Radiesse is composed of calcium hydroxyapatite

microspheres in a water-based gel carrier, and has

been used for many years in the treatment of vocal fold

insufficiency and as a radiological tissue marker.6

As a

soft tissue filler, it acts as a scaffold for stimulating col-

lagen production. It should be injected in a retrograde

fashion in the subdermal plane. Placement of this filler

too superficially may result in a whitish skin discol-

oration and palpable irregularities. After placement, it

is helpful to massage the area to position the filler in

the desired location and to mold the material to the

desired shape into the tissue.

We most often inject hyaluronic acids in an antero-

grade fashion, except for the glabellar region, where vas-

cular occlusion can be a devasting, vision-compromising

complication (Fig. 17.2). If the material is injected too

superficially, or the overlying skin is translucent, the

Tyndall effect or a grayish discoloration in the region will

be evident. Overcorrection is not recommended. After

injection, gentle massage may be performed to achieve a

smooth and continuous contour with the surrounding

tissue. Repeat injection may be performed at 1-week

intervals until the final correction is achieved.

THE FOREHEAD

Treating the brow depressors with botulinum toxin to

modify brow level and contour has become standard

practice. Understanding this concept has encouraged

injectors to also modify their treatment of forehead

rhytids. Botulinum toxin injections across the forehead

can effectively obliterate forehead rhytidosis, but

lower the brow level and alter the eyebrow arch.This

unwanted brow lowering and flattening is particularly

evident in patients who utilize their frontalis muscle to

compensate for their blepharoptosis or heavy, redun-

dant upper eyelid folds.

To allow for full frontalis muscle action, and brow

elevation, forehead botulinum toxin injections should

be limited to the central forehead and the upper

third of the forehead. We prefer to use 2.5 units of

Botox per injection site in this region. Residual lateral

brow peaking, should it occur, can be treated (dose

adjustment) after 1–2 weeks at a follow-up visit. The

injections should be placed in the area where the


Table 17.3 Particle sizes of Q-Med Sweden hyaluronic

acid products

Product Gel particle size (µm)

Restylane 250

Perlane 1000

Fine Lines 150

Restylane SubQ Approx. 2000

Restylane Touch 100


rhytid is formed by the frontalis, but never closer than

1 cm to the brow.

Residual lateral dynamic rhytids are best treated

with volumetric radiofrequency (RF) skin tightening

(Thermage) and hyaluronic acid fillers.The choice of

filler is dictated by the depth of the static component

of the rhytid. Most often we prefer the mildly viscous

hyaluronic acids (Restylane or Juvederm Ultra). But,

for superficial rhytids, we prefer superficial filling with

minimally crosslinked hyaluronic acids (Restylane Fine

Lines, Restylane Touch, or Captique) or localized

intradermal plumping with non-crosslinked hyaluronic

acids (Restylane Vital or SurgiLift).

THE PERIORBITAL AREA

The periorbital area lends itself very well to noninvasive

therapeutic modalities that can improve skin texture and

redundancy and camouflage irregular contours.

Botulinum toxin is the first step in periorbital reju-

venation, reestablishing an appropriate eyebrow–

eyelid relationship, correcting brow ptosis (20–40

units to depressor supercilli muscles at 5 units of

Botox per injection site), and enhancing effective col-

lagen remodeling with orbicularis muscle relaxation

(15–20 units to lateral canthal and lower lid pretarsal

orbicularis muscles at 2.5 units per injection site), or

even compensating for mild blepharoptosis (2.5 units

to lateral upper lid pretarsal orbicularis muscle).

Eyelid skin quality, texture, pigmentation, redun-

dancy, and subcutaneous vascular pooling can then be

addressed with biweekly intradermal and subcuta-

neous carbon dioxide eyelid insufflation (CO2

Cellulair) augmented with volumetric RF eyelid skin

tightening (Thermage eye tip) (Fig. 17.3). Further

enhancement of eyelid texture and pigmentation can

be achieved with one to three treatments with a pixe-

lated erbium laser (Alma Laser Pixel). Pretreatment

with botulinum toxin is essential for maximal collagen

remodeling.

Residual contour irregularities (tear trough,

infraorbital, or lateral orbital sulcus deformities)

can be camouflaged with mildly crosslinked

hyaluronic acid (Restylane or Juvederm) (Fig. 17.4).We

prefer the limited puncture technique, implanting

the injected hyaluronic acid in the suborbicularis

supraperiosteal plane and massaging it into

position10–12

(Fig. 17.5).

THE MIDFACE

Approaching the midface with a combination of tight-

ening and filling can effectively yield a very natural

result. Pretreating the entire midface with volumetric

RF dermal heating (Thermage) and reinforcing with

submalar and preauricular vectors will elevate the

malar eminences. Further malar augmentation can

be accomplished with longer-lasting more-viscous


Fig.17.2 (a) It is important to realize that furrows present at rest will need fillers in addition to muscle relaxation with

botulinum toxin. (b) The glabella furrows were treated with 40 units of botulinum toxin and 0.5 ml Perlane.

a b


hyaluronic acid (Perlane, Juvederm Ultra plus, or

Restylane SubQ) or poly-L-lactic acid (Sculptra) or

Hydroxyapatite (Radiesse).

Lipoatrophy of the midface with sunken cheeks and

redundant nasolabial folds needs larger volumes of

deeper, longer-lasting filling material. In our experi-

ence, Sculptra and autogenous fat work best for this

purpose. Supporting the malar and cheek areas, we fill

out the face, support the midface, and redrape the

nasolabial folds (Fig. 17.6).


Fig.17.3 CO2 Cellulair insufflation presumably enhances subcutaneous and cutaneous perfusion. (a,b) These patients have

mild pigment irregularities and shadows secondary to vascular pooling.They are good candidates for CO2 Cellulair™ treatment.

(c, d) CO2 Cellulair insufflation has improved eyelid skin quality, texture, pigmentation, redundancy,and subcutaneous vascular

pooling after four weekly treatments.

Fig.17.4 Periorbital contour deformities can be camouflaged with hyaluronic acids. (a) This patient assumed that she had

lower lid cutaneous pigmentary abnormalities. In fact, the dark circles that she saw on her lower lids were shadows secondary to

prolapsing orbital fat. She was not emotionally prepared for a lower lid blepharoplasty, but did consent to correction with

Restylane. (b) This patient was treated with suborbicularis, supraperiosteal placement of Restylane to correct her tear trough

deformities.

a

c

b

d

a b


Midface lifting can also be enhanced with implantation

of a more-viscous, longer-lasting material injected into

the canine fossa.We have found Radiesse to be effective

for this purpose, supporting the midface and softening

the nasolabial grooves. Using 0.5–1.0 ml of Radiesse can

achieve significant midface lifting.The effect can be fur-

thered with additional Radiesse implanted subcutaneously

under the nasolabial grooves13

(Figs. 17.7 and 17.8).


Fig.17.5 (a–c) Two aliquots of 0.2 ml are placed above the periosteum along the medial aspect of the inferior orbital rim and

massaged into place. (Reproduced from Bosniak S et al. The ‘Restylane push’ technique for the treatment of the nasojugal groove.

Submitted for publication.10

Fig.17.6 (a) Because of this patient’s relatively deep nasolabial folds, thick skin,and mild midfacial ptosis,we injected

Radiesse trancutaneously in the canine fossa to fill her nasolabial folds and to give her some midface-lifting effect. (b) She has

achieved a reasonable midface lifting and filling of her nasolabial folds; in addition,her multicontoured melomental folds were

filled with Sculptra.

a b c

a b



0.5 ml27 gaugeRadiesse

Digital massage Nasolabial fold fills-inmicrolift

Fig.17.7 (a) Using a 27-gauge needle,0.5 ml of Radiesse is injected into the canine fossa on each side just above the

periosteum anterior to the maxilla. (b) A sectional view shows digital massage over the bolus. (c) Filling of nasolabial folds.

Fig.17.8 (a) Like the patient shown in Fig.17.7, this patient had relatively deep nasolabial folds, thick skin,

and mild midfacial ptosis, and again we injected Radiesse trancutaneously in the canine fossa to fill her nasolabial folds

and to give her some midface-lifting effect. (b) She has achieved a significant mid-face lifting and filling of her

nasolabial folds.

a b

cba


In addition, the hyaluronic acids can be very useful in

effectively recontouring nasal deformities (Figure 17.9).

THE PERIORAL AREA

The most prominent area of the lower third of the

face is the mouth. Full lips transmit youth and sensu-

ality. Perioral rhytids and thin lips give the impres-

sion of age, detachment, and coldness. Rejuvenating

the lips is not simply about size or the lips them-

selves. It necessitates a balance between the lips,

mouth, and the entire lower third of the face. Thin

lips create too large a space between the nose and

the upper lip and the appearance of an elongated,

unattractive upper lip.

Lips can be augmented and recontoured effectively

with a combination of hyaluronic acid products of dif-

ferent viscosities.The upper lip can be accentuated and

vertical rhytids softened with less-viscous materials,

whereas the body of the lip is more efficiently filled

with more-viscous products.

For the border of the lip, we prefer to use

Restylane, Juvederm Ultra, Captique, or Cosmoplast.

Cosmoplast may be useful for the border, since it is

mixed with lidocaine, facilitating painless filling of the

body of the lip.

For the body of the lip, if an increased volume is

necessary for augmentation, Perlane and Juvederm

Ultra plus work well. Restylane and Juvederm Ultra

are also effective for this area (Figs 17.10 and

17.11).

Melomental folds, also known as marionette lines,

and the downturning corners of the mouth can be

ameliorated with the combination of filling agents and

neuromodulation of the depressor oris angulii

(DAO). The DAO arises fom the border of the

mandible and inserts on the lateral corners of the

mouth. This muscle contributes to the depth of the

melomental fold and to the downward displacement

of the lateral corners of the mouth. Relaxing the DAO

allows the zygomaticus major and minor to elevate

the corner of the mouth without opposition, raising

the lateral corners and facilitating filling of the oral

commissures.4

Restylane or Perlane may then be

injected into the corners of the mouth to create a but-

tress. Sculptra can then be injected, utilizing the fan-

ning technique to fill the multicontoured areas of the

oral commissures and melomental depressions.

Vertical upper lip rhytids may be treated with a

combination of fillers (Restylane, Restylane Fine

Lines, and Captique) using delicate cross-hatching and

Botox at a maximum of 4 units spaced equidistant

from each other and at least 1 cm from the midline. It

is important to avoid asymmetry and incompetence of

the orbicularis oris. Patients should be warned about

difficulty whistling, smoking, and sipping through a

straw. Pixel-fractionated erbium : yttrium aluminum


Fig.17.9 (a, b) Restylane and Perlane were used to correct these nasal deformities while the patient was contemplating

corrective surgery.

a b


garnet (Er:YAG) laser resurfacing can further enhance

the final result.

THE NECK

Neck rejuvenation has a balancing and complementary

role in the whole approach to a youthful appearance

of an individual. The elements that influence the

appearance of the neck are the quality and texture of

the skin; the firmness of the subcutaneous fat; the

strength, thickness, and form of the platysma muscle;

subplatysmal fat; and the anatomy and prominence

of submaxillary glands, thyroid cartilage, and the

surrounding bones.14

Relaxing the muscles of the neck using chemod-

enervation agents can improve the appearance of the

neck and at the same time prepare the overlying tissues


Fig.17.10 (a) Although the lip volume was adequate, the border was ill-defined. (b) Restylane was used to accentuate the

border of the upper lip.

Fig.17.11 (a) Lower facial laxity and a disappearing upper lip were this patient’s main complaints. (b) This patient was

treated with a combination of Thermage to the pre-jowl sulcus and lower face, botulinum toxin to the depressor oris anguli,

Perlane to the body of the lip and corners of the mouth,and micropigmentation to the lips.These treatments gave her a better

balance of the lower one-third of her face and decreased the distance between the upper lip border and her nose.

a b

a b


to be maximally rejuvenated with complementary

treatments. Prominent platysmal bands and horizontal

neck rhytid formation are due to hyperkinetic acitivity

and loss of tone of the platysmal muscle.15

Botox can

be injected into the platysmal bands and necklace

lines. Results are better for platysmal bands than for

necklace lines because the latter are often not directly

related to platysma muscle activity. Necklace lines are

notoriously difficult to treat, but we have found that a

combination of CO2 Cellulair (CO2

gas insufflation)

and intradermal injection of non-crosslinked hyaluronic

acid (Restylane Vital or Surgilift – neither of which is

available in the USA) works well following pretreatment

of the platysma with botulinum toxin.

We routinely inject botulinum toxin into the platys-

mal bands using 2.5 units per injection site along the

length of the band before treating the skin of the neck

and submental area with volumetric RF deep dermal

heating (Thermage). Stacked pulses of Thermage in

the submental area will enhance the lipolytic effect

(Fig. 17.12).When treating submental fat, other com-

plementary noninvasive techniques include injection

of phosphatidylcholine and deoxycholate, and intra-

dermal and subdermal CO2 Cellulair for the further

improvement of submental contour and reduction of

the submental fat pocket.

REFERENCES

1. Holds JS, Alderson, Fogg SG, et al. Terminal nerve and

motor end plate changes in human orbicularis muscle fol-

lowing botulinum A exotoxin injection. Invest Ophthalmol

Vis Sci 1990;31:178–81.

2. Coffield JA, Considine RV, Simpson LL. The site and

mechanism of action of botulinum neurotoxin. In:

Jankoric J, Hallet M, eds.Therapy with Botulinum Toxin,

4th edn. New York: Marcel Dekker, 1994:3–13.

3. Carruthers J, Fagien S, Matarasso SL. Botox Consensus

Group: consensus recommendations on the use of botu-

linum toxin type A in facial aesthetics. Plast Reconstr

Surg 2004;114:1S–22S.

4. Bosniak S. Neuromodulation and management of

facial rhytidosis. In: Bosniak S, Cantisano-Zilkha M,

eds. Minimally Invasive Techniques of Oculofacial

Rejuvenation. New York:Thieme, 2005:32–42.

5. Ellis DA, Makdessian AS, Brown DJ. Survey of future injecta-

bles. Facial Plast Surg Clin North Am 2001;9:405–11.

6. Glavas IP. Filling agents. Ophthalmol Clin North Am

2005;18:249–57.

7. Gladstone HB,Wu P, Carruthers J. Background informa-

tion on the use of esthetic fillers. In: Carruthers J,

Carruthers A, eds. Soft Tissue Augmentation. Philadelphia:

Elsevier,2005:1–9.

8. Rzany B, Zielke H. Overview of injectable fillers. In: de

Maio M, Rzany B, eds. Injectable Fillers in Aesthetic

Medicine. Berlin: Springer-Verlag, 2006:1–9.


Fig.17.12 (a) Lower facial laxity is demonstrated here, accentuating the melomental folds, and this creates a multicontoured

area that requires more than fillers alone for an optimal result. (b) This patient had botulinum toxin to the platysma and

depressor oris anguli to raise the corners of her mouth;Thermage was used to tighten the skin over the melomental folds, and

Sculptra to fill the melomental sulcus.

a b


9. Bowman PH, Narins RS. Hylans and soft tissue augmen-

tation. In: Carruthers J, Carruthers A, eds. Soft Tissue

Augmentation. Philadelphia: Elsevier, 2005:33–53.

10. Bosniak S, Sadick NS, Cantisano-Zilkha M, et al. The

‘Restylane Push’ technique for the treatment of the naso-

jugal groove. Submitted for publication.

11. Bosniak S, Sadick NS, Cantisano-Zilkha M, et al.

Definition of the tear trough and the tear trough rating

scale (TTRS).Arch Facial Plast Surg (in press).

12. Bosniak S, Cantisano-Zilkha M, Purewal BK, Rubin M,

Remington BK. Defining the tear trough. Ophthalmol

Plast Reconstr Surg (in press).

13. Zdinak L, Bosniak S, Sadick NS, et al. Midface lift with

Radiance FN: a minimal puncture technique. Submitted

for publication.

14. Glavas IP, Bosniak S. Noninvasive neck rejuvenation. In:

Bosniak S, Cantisano-Zilkha M, eds. Minimally Invasive

Techniques of Oculofacial Rejuvenation. New York:

Thieme, 2005:65–72.

15. Matarasso A, Matarasso SL. Botulinum A exotoxin for the

management of platysma bands. Plast Reconstr Surg

2003;112(5 Suppl):138S–40S.



INTRODUCTION

Volume loss has become increasingly recognized as an

important, if not primary, process that occurs during

the aging process. Accordingly, soft-tissue fillers

and facial fat grafting have assumed a greater role in a

global strategy for facial rejuvenation. In the past,

traditional surgical modalities were focused heavily on

lifting redundant, prolapsed, and descended tissues.

The new paradigm today is to view the face like a grape

that, over time, deflates and shrivels into a raisin.

Volume replacement will restore the raisin to a grape,

while cutting away the excess skin will turn it into a

tiny pea.The analogy to the aging face is overly simplis-

tic, but contemporary facial rejuvenation must include

some degree of volume restoration if it is to appear

natural. In our opinion, a complementary approach

that incorporates facial fat grafting for volume restora-

tion along with facial lifting procedures and dermato-

logical therapies will often provide the greatest

improvement for a particular individual.

The new paradigm of the aging face that views the

primary mechanism of aging as volume contraction

focuses on issues that are remarkably different from

those that are important in lifting procedures. The

volume and shape of the face takes centerstage. The

youthful face is viewed as triangular or heart-shaped,

but over time becomes more rectangular in appear-

ance due to loss of midface volume and accumulation

of fullness in the jowls.Volume restoration is aimed at

returning the face to a more heart-shaped configura-

tion by targeting the midface/cheek region and the

chin/prejowl area in order to simulate the highlights

of youth. Autologous fat transfer is often combined

with a traditional cervicofacial rhytidectomy along

with microliposuction of the jowl to narrow and taper

the lower face (Fig. 18.1).

Another important objective of facial fat grafting is

to restore the youthful frame of the eye. In the same

manner as a picture, the beauty of the eye is accentu-

ated by a flattering frame and diminished when not

adequately framed. Periorbital fullness is the hallmark

of a youthful framed eye.Traditional blepharoplasty is

contingent upon removing the frame of the eye rather

than restoring it primarily through aggressive removal

of orbital fat. The result is a skeletonized and aged

appearance. Complementary fat grafting advocates

conservative removal of redundant upper eyelid skin

and reduction of lower eyelid pseudoherniated fat,

combined with periorbital fat, grafting to achieve a

natural and youthful result (Fig. 18.2).

We perform far fewer browlifts today, as this opera-

tion accentuates the unattractive long rectangular

shape of the aging face and further skeletonizes the

orbital rim. The new aesthetic favors the naturally

appearing lower and fuller brow compared with a

more superiorly situated and sculpted ‘done’ brow. A

useful guideline to determine what is suitable for a

particular patient is to review his or her old photo-

graphs to evaluate precisely how full or how high the

eyelids and brow were at a young age. In this way, we

can strive to help an individual look more like himself

or herself at a younger age rather than an arbitrary and

often inaccurate definition of what would look aes-

thetically pleasing. Unfortunately, too often, men and

women look different after traditional surgery and less

like they did when they were younger. Facial fat graft-

ing, at times combined with traditional surgery, offers

the ability to more closely approximate an individual’s

younger self.

18. Adjunctive techniques III:

complementary fat grafting

Robert A Glasgold, Mark J Glasgold, and Samuel M Lam



Fig.18.1 Preoperative (a) and postoperative (b) photographs of a patient who underwent a deep plane facelift, lower lid

transconjunctival blepharoplasty,and upper lid blepharoplasty, combined with fat transfer to superior and inferior orbital rim,

midface,and prejowl sulcus.

Fig.18.2 (a) This patient has a prominent-appearing eye following an aggressive isolated lower lid transconjunctival

blepharoplasty. (b) An attractively framed eye following periobital and midface fat transfer.Reprinted with permission from Lam

SM,Glasgold MJ,Glasgold RA.:Complementary Fat Grafting. Philadelphia:Lippincott Williams & Wilkins;2007.

a b

a b


PREOPERATIVE CONSIDERATIONS

Anatomy

Periorbital volume restoration is of primary importance

in creating an appropriately full frame around the eye.

The most important component of the ‘frame’ is the

inferior orbital rim. Reviewing photographs of models

allows us to understand this aesthetic ideal.Variations in

the upper periorbital frame exist, with the most com-

mon appearance being a full brow with a few millime-

ters of the upper lid skin visible (Fig. 18.3). Some very

attractive individuals have relatively sculpted and hol-

lowed brow/upper eyelid complexes, but uniformly

every young beautiful face has a full lower eyelid that

blends seamlessly with a full cheek. Again, review of an

individual’s old photographs will help determine what is

a natural appearance for the specific patient. As already

mentioned, significant pseudoherniation of lower

orbital fat will benefit from selective reduction via a

transconjunctival blepharoplasty combined with con-

current filling of the inferior orbital rim by autologous

fat transfer. Similarly, a truly deflated and hanging upper

eyelid would be best approached with conservative

removal of redundant skin, with some degree of fat

transfer into the brow (Fig. 18.4).

The cheek is an extension of the lower frame of

the eye and is a vital component of a youthul heart-

shaped face. The cheek can be divided into anterior

and lateral components. With advancing age, the

anterior cheek, which develops the most significant

volume loss along the malar septum, is a primary

target for fat transfer. The lateral cheek, when

restored, should reveal the lustrous highlight that is

associated with a convex youthful shape (Fig. 18.5).

Often, the buccal region must be volume-enhanced,

as it becomes relatively hollow after augmentation of

the malar region. However, care must be taken to

avoid overfilling this area if the patient desires the

more sculpted look that manifests in one’s 30s as

opposed to the fuller oval shape of someone in their

early 20s.

Placement of fat into the precanine fossa and

nasolabial fold is not so much intended to efface the

linear depression but rather to provide an improved

contour from the newly augmented cheek to the

upper lip.We believe that any one of a number of avail-

able dermal fillers is more useful for elimination of the

nasolabial and labiomandibular folds. Similarly, lip

augmentation with fat grafting only yields subtle

results after considerable and protracted postoperative

edema.

Complementary fat grafting 207

Fig.18.3 A youthful face with an attractive periorbital

frame.This young woman (who has not had surgery)

demonstrates a full upper eyelid with only several millimeters

of lid skin visible and a lower eyelid that transitions

seamlessly into a full cheek.

Reprinted with permission from Lam SM,Glasgold MJ,

Glasgold RA.:Complementary Fat Grafting.

Philadelphia:Lippincott Williams & Wilkins;2007.


Facial fat grafting of the lower face is centered on

finishing the lower point of the triangle of a youthful

countenance.Therefore, the focus of fat grafting along

the lower face is concentrated in the prejowl sulcus,

anterior chin, labiomental sulcus, and labiomandibular

depression. Augmentation of the lateral mandible can-

not be undertaken concurrently with a facelift due to

undermining of the skin in this portion of the face.

Patients with mild jowling or prejowl volume loss can

achieve a very good restoration of the jawline with fat

grafting alone. In contrast, we have found that it is dif-

ficult to truly attain a straightened jawline with facial

fat grafting alone in patients who have a heavy jowl and

that, for optimal patient and surgeon satisfaction, a

facelift should be incorporated for these patients.

However, augmentation of the prejowl with fat graft-

ing can enhance the result of any facelift, and is incor-

porated into most of our rhytidectomies (Fig. 18.6).

Consultation

As with any cosmetic consultation, the ultimate goal is

to establish aesthetic objectives for surgical and/or

nonsurgical intervention mutually agreed between the

surgeon and the prospective patient. Besides the stan-

dard psychological, emotional, and aesthetic consider-

ations that are part of every initial patient encounter,

the surgeon must establish aesthetic goals, realistic

expectations, and an understanding of the potential

recovery period that relate specifically to fat grafting.

These unique considerations will be elaborated in this

section, and can be incorporated into the framework

of a standard consultation.

Often during the consultation, the patient must be

refocused on what truly gives them an aging appear-

ance. Women, in particular, focus on fine lines that

typically achieve disproportionate importance when


Fig.18.4 Preoperative (a) and postoperative (b) photographs of a patient who underwent upper lid skin-only blepharoplasty,

lower lid transconjunctival blepharoplasty,and periorbital and midface fat transfer.

a b



Fig.18.5 Preoperative (a) and postoperative (b) photographs of a patient who underwent transconjunctival lower lid

blepharoplasty and periorbital and midface fat transfer.Reprinted with permission from Lam SM,Glasgold MJ,Glasgold RA.:

Complementary Fat Grafting. Philadelphia:Lippincott Williams & Wilkins;2007.

Fig.18.6 (a) Patient following a facelift,with the appearance of persistent jowling. (b) Volume augmentation of the prejowl

sulcus creates a straight jawline.Reprinted with permission from Lam SM,Glasgold MJ,Glasgold RA.:Complementary Fat

Grafting. Philadelphia:Lippincott Williams & Wilkins;2007.

a b

a b


viewed with a magnifying mirror and bright illumi-

nation during makeup application. The consultation

aims to recalibrate their thinking to evaluate their

face the way other people see them from conversa-

tional distances. Additionally, we point out that they

primarily see themselves only in frontal view in a

mirror, whereas in the real world they are usually

seen at an oblique angle.To help the patient appreci-

ate this, we will often take digital images of the

patient and review these with them. Volume and

shape are emphasized over fine wrinkles and minor

cutaneous blemishes, which, to reiterate, are not

truly ameliorated with facial fat grafting. Digital

imaging of possible results plays a very limited role

in the discussion of facial fat grafting. It is almost

impossible to demonstrate the benefits of fat grafting

with digital morphing analysis, since the technology

is two-dimensional and the operative intervention

is three-dimensional. Instead, use of a catalog of

before-and-after photographs of patients whom the

surgeon has taken care of is perhaps the most effec-

tive way of demonstrating to the patient the benefits

of fat grafting.

Showing patients how they may look at 1 week, 2

weeks, 1 month, etc. after surgery provides the most

useful information about potential recovery time.

Most often, when an individual views other patients

during this early recovery period, he or she may not

perceive that they look very swollen, just better.

However, it is important to emphasize that most of

these patients were uncomfortable with the way they

looked during the first 2–3 weeks following surgery.

These psychological details are helpful to discuss with

each patient in the preoperative setting. Use of old

photographs can also be very enlightening both for the

patient and for the surgeon.The patient should readily

grasp the volume changes associated with aging, and

the surgeon can better discuss with the patient what

aesthetic changes will be most beneficial toward

reestablishing a youthful appearance.As already stated,

many women do not like the fullness, often referred to

as ‘baby fat’, that is prevalent in their teens and early

20s, but prefer the relative sculpted (but not yet

hollow) appearance of themselves in their late 20s to

early 30s.

OPERATIVE TECHNIQUE

Donor harvesting

For very thin individuals, it may be advisable to evalu-

ate potential donor sites during a preoperative visit.

Generally speaking, most patients will be able to

inform the surgeon where they have abundant fat. For

instance, men are predominately truncal-dominant,

whereas women can either be truncal (abdomen/

waist) or extremity (inner or outer thigh) dominant.

For very thin individuals or those who have undergone

extensive prior body liposuctioning, the lower back

and triceps may be ideal reserves that remain for har-

vesting. Most commonly, the lower abdomen and

inner thigh serve as excellent donor sites for fat

harvesting if intraoperative patient repositioning is

problematic.

Before lower abdomen harvesting is undertaken, it

is imperative to inquire what abdominal procedures

the patient has had in the past and to evaluate the dis-

tribution of abdominal scars. In order to ensure that

the patient does not have an occult ventral or umbilical

hernia, the surgeon should ask the patient to Valsalva in

a supine position with his or her head elevated for

optimal evaluation. Obviously, a hernia in the field of

harvesting would preclude harvesting in that area.

Many aesthetic surgeons who are uncomfortable with

body harvesting express trepidation about uninten-

tional violation of the visceral cavity during harvesting.

This outcome is very unlikely, especially under con-

scious sedation, given the thickness of the muscular

fascia as well as the exquisite discomfort elicited when

the fascia is even abraded with the harvesting cannula.

For the inner thigh, the surgeon must ensure that the

cannula passes through a superficial fascial layer before

fat harvesting can commence. Superficial passage of

the cannula is evident by the visibility of the cannula

through the skin, which should be immediately cor-

rected to avoid a potential contour deformity in the

donor area.

Although fat grafting can be undertaken with any

level of anesthesia, we have found that intravenous

sedation provides excellent pain control and patient

compliance. After the patient is adequately sedated,



the donor area is infiltrated with 0.25% lidocaine with

1:400 000 epinephrine using a 20 cm3

syringe outfit-

ted with a 22-gauge spinal needle. (The mixture is

attained by combining 5 cm3

of 1% lidocaine and

1:100 000 epinephrine with 15 cm3

of normal saline.)

If the patient is under oral sedation, then a higher per-

centage of lidocaine (0.5% lidocaine with 1:200 000

epinephrine) should be used to improve patient com-

fort. (The mixture is attained by combining 10 cm3

of

1% lidocaine and 1:100 000 epinephrine with 10 cm3

of normal saline.) When allocating the 20 cm3

of local

anesthesia, the surgeon should aim to place 10 cm3

in

the deep aspect of the fat pad (immediately above

the muscle/fascia) and 10 cm3

into the immediate

subcutaneous plane, leaving the bulk of the fat pad

untouched with anesthetic.

After the patient has been sterilely prepped and

draped, a 16-gauge Nokor needle (or No.11

Bard–Parker blade) is used to make a stab incision for

entry of the harvesting cannula. For lower abdominal

harvesting, the incision can be made inside the lower

aspect of the umbilicus or suprapubically, and for the

inner thigh, it can be made along the inguinal crease.

Many different types of harvesting cannulas can be

used.We prefer a 3 mm bullet-tipped cannula for har-

vesting (Fig. 18.7). All harvesting is undertaken with a

10 cm3

syringe manually, i.e., without machine assis-

tance, using only 1–2 cm3

of negative pressure on the

plunger.A few technical pearls that can help the novice

surgeon undertake harvesting easily and effectively

should be enumerated. First, the surgeon should

attempt to remain within the middle substance of the

fat pad. Rippling of the skin with passage of the cannula

indicates that the cannula is too superficial.The surgeon

should always be cognizant of where the cannula tip

resides, as the tip is the active end where fat enters. If

the cannula tip abrades the deep fascia or goes beyond

the anesthetized area, the patient can experience undue

and unnecessary discomfort. As the surgeon continues

harvesting, the cannula should be retracted almost back

to the entry site before redirecting to the adjacent site.

If the cannula tip is not withdrawn prior to directing it

to an adjacent site to continue harvesting, the surgeon

will effectively be harvesting in the same passage site,

not in a new area.While harvesting, the nondominant

hand should stabilize the fat pad, not squeeze or deform

the donor area, to prevent uneven harvesting and

potential donor-site contour deformity.When harvest-

ing, the surgeon should recall that usable fat will be

about one half the harvest volume, e.g., each 10 cm3

syringe will yield approximately 5 cm3

of viable fat.

Processing the fat

The next step is processing the fat.The 10 cm3

syringes

are placed in the centrifuge and spun for approximately

2–3 minutes at 2000 to 3000 rpm.This will sufficiently

separate the unwanted blood, lidocaine, and lysed fat

cells from viable fat cells. Before centrifugation, each

10 cm3

syringe must be outfitted with customized caps

and plugs to ensure that the contents do not spill out

during the centrifugation process. It is imperative not to

use the prepackaged plastic caps that fit onto the Luer-

Lok side, as they will invariably become detached dur-

ing centrifugation. It should also be emphasized that the

centrifuge should be able to accommodate either sterile

individual sleeves that hold each syringe or, alterna-

tively, an entire central rotary element that holds all of

the syringes, which can be removed and sterilized.

After the fat has been centrifuged, the supranatant

(from the plunger side), consisting of lysed fat cells, is

poured off. Only after removing the supranatant is the

Luer-Lok cap removed and the infranatant drained. A

noncut 4 × 4 gauze (or cotton neuropaddy) is placed

into the plunger side, making contact with the column

of fat in order to wick the remaining supranatant away.

After 5–10 minutes, the column of fat is then poured

from the open plunger side of the 10 cm3

syringes into

the open plunger side of a 20 cm3

Luer-Lok syringe.

The 20 cm3

syringe should not be filled beyond the

15 cm3

mark. When pouring the fat into the 20 cm3

syringe, the surgeon should attempt to keep any resid-

ual bloody infranatant in the original 10 cm3

syringe.A

Luer-Lok transfer hub allows transfer of fat from the

20 cm3

syringe into 1 cm3

Luer-Lok syringes used for

fat injection.The plunger on the 1 cm3

syringe should

be drawn all the way until it is actually removed from

the syringe while filling the syringe with fat, so as to

eliminate the air bubble that typically resides between



the plunger and the end of the fat column.The plunger

is then returned to the 1.0 cm3

mark to maintain

accurate volume counts.

Fat infiltration

The following general principles of technique will help

to optimize results and minimize problems. The pri-

mary principle behind safe fat grafting, particularly

when learning the technique, is to ‘hit doubles’ rather

than strive for a ‘home run’. Placing too much fat into

any area, especially in the periorbital region, is very

difficult to correct, whereas placement of additional

fat can be easily and quickly undertaken in a second

session (see ‘Management of complications’ below).

Placement of fat is done only in small parcels

(0.03–0.05 cm3

per pass for sensitive areas and

0.1 cm3

per pass in more forgiving zones) in order to

attain optimal fat cell survival by allowing maximal

contact of each particle with the surrounding tissue

and neighboring blood supply.The use of blunt cannu-

las (Fig. 18.7) (Tulip Medical Inc., San Diego, CA;

Byron Medical Inc., Tucson, AZ; Miller Medical Inc.,

Mesa, AZ) allows for less traumatic insertion of fat,

resulting in less bruising and swelling.While injecting fat,

the nondominant hand is used to palpate the underlying

bony landmarks (to be discussed below) in order to

guide the passage of the cannula in the correct depth and

location. Finally, as the cannula tip cannot be visualized,

the surgeon must mentally envision the depth of the tip

during the procedure. We have divided the injection

planes into three basic levels, which will be referred to

throughout this section on infiltration technique, as deep

(corresponding to the supraperiosteal level), medium

(the musculofascial or deep subcutaneous level), and

superficial (the superficial subcutaneous depth).

Recipient site anesthesia

The three skin entry sites (A: midcheek; B: lateral can-

thal; and C: posterior to the prejowl sulcus) are infil-

trated with 1% lidocaine with 1:100 000 epinephrine

(Fig. 18.8).Then, appropriate facial regional blocks are

performed, usually including the infraorbital, zygo-

maticotemporal, zygomaticofacial, and supraorbital

nerves. An 18-gauge needle is used to create the three

entry sites on each side of the face.The same infiltra-

tion cannula intended for fat infiltration is used to

inject local anesthesia (1% lidocaine with 1:100 000

epinephrine) into the planned recipient sites in order

to minimize tissue trauma.

Inferior orbital rim

The inferior orbital rim is the area that requires special

attention in terms of both total volume placed and tech-

nique. Fat grafting to the inferior orbital rim is done

through an entry site on the cheek, which allows the fat

to be deposited perpendicular to the bony orbital rim.

In our experience, a lateral-based entry point in which

the cannula is passed parallel to the orbital rim con-

tributes to an unacceptably high incidence of fibrotic fat

bulges. Generally speaking, for the beginning surgeon,

we advocate placement of 1 cm3

of fat along the medial

inferior orbital rim and 1 into the lateral inferior orbital

rim.The fat is injected into the deep (supraperiosteal)

plane.The nondominant index finger is used to palpate

the rim to confirm the appropriate cannula depth and to

guard against injury to the globe (Figure 18.9). As the

cannula tip is passed perpendicularly across the inferior

orbital rim (about 1 mm in either direction), 0.05 cm3

of fat is layered per pass of the cannula. Additional fat


Fig.18.7 The Glasgold Fat Transfer Set (Tulip Medical

Inc.): 0.9 mm × 4 cm blunt spoon-tip infiltration cannula;

1.2 mm × 6 cm blunt spoon-tip infiltration cannula;

2 mm × 12 cm multiport harvesting cannula;3 mm × 15 cm

bullet-tip harvesting cannula.Reprinted with permission

from Lam SM,Glasgold MJ,Glasgold RA.:

Complementary Fat Grafting. Philadelphia:Lippincott

Williams & Wilkins;2007.


can be placed for more volume-depleted patients at a

medium depth. Fat infiltration superficial to the orbicu-

laris oculi muscle is not recommended.The supramus-

cular plane in this region has no added advantage, and

has significant potential for contour irregularity.We rec-

ommend being conservative with volumes in this area

until the surgeon is comfortable with the technique.

Even for the more experienced fat injector, we caution

against exceeding 4 cm3

in the infraorbital rim at one

setting in order to minimize problems.

Superior orbital rim/brow

The primary objective in filling the superior orbital

rim is to re-establish a youthful appearing lateral brow

convexity. Filling a markedly hollow upper eyelid sulcus

is an advanced technique, lying beyond the scope of this

chapter. Placement of fat along the superior orbital rim

can be undertaken easily from a lateral entry point and

rapidly filled using 0.1 cm3

per pass without difficulty or

significant risk of contour deformity.The passage of the

cannula should follow the plane of least resistance.The

appearance of this area being overfilled may arise toward

the end of augmentation – this should give rise to alarm,

as it will settle over time. Generally, 2 cm3

of fat begins

to restore the deflated lateral-brow convexity.

Nasojugal groove

The nasojugal groove is the triangular depression out-

lined superiorly by the medial inferior orbital rim and

medially by the nasal sidewall. For the purposes of fat

transfer, we make a distinction between the nasojugal

groove and the tear trough.The latter is distinguished

as the visible depression in the region of the medial

orbital rim, which, depending on a patient’s particular

anatomy, may or may not directly correlate with the

bony nasojugal groove.The nasojugal groove is gener-

ally filled with 1 cm3

of fat, which can be placed

quickly with 0.1 cm3

per pass of the cannula.

Anterior cheek

The area of greatest volume loss in the anterior cheek

is usually along a linear depression running from

superomedial to inferolateral, corresponding to the

malar septum. The anterior cheek is infiltrated from

the lateral canthal entry point. As the cannula passes

through the anterior cheek, it is common to feel resis-

tance from the malar septum.The primary areas of fat

deposition in the anterior cheek are along the malar

septum and anteromedial to it. Caution should be

taken to not overfill this region in men, as this may

feminize the face. In general, 3 cm3

of fat are injected,

with 0.1 cm3

per pass.The surgeon should try to visu-

alize the passage of the cannula from a deeper to a pro-

gressively more superficial plane to distribute the fat

cells more widely and thereby enhance the potential

for adipocyte survival. The volumes used can be

increased as needed for more volume-depleted

patients. Anterior cheek volumes should be more

conservative in males, where a fuller anterior cheek

will tend to feminize the face.


Fig.18.8 The three red marks correspond to the planned

entry sites for fat injections:midcheek (A), lateral canthus

(B), and posterior to the prejowl sulcus (C).The black marks

indicate the areas for planned fat injections.Reprinted with

permission from Lam SM,Glasgold MJ,Glasgold RA.:

Complementary Fat Grafting. Philadelphia:Lippincott

Williams & Wilkins;2007.


Lateral cheek

The lateral cheek highlight is a very important youthful

landmark to restore. Approached from the midcheek

entry point, the area overlying the lateral zygoma is

augmented with 2–3 cm3

of fat. The injection can be

tapered into the submalar region as needed.The tech-

nique of gradual progression from a deep to a superfi-

cial plane and placement of 0.1 cm3

per pass is the same

as that described for anterior cheek augmentation.

Buccal

Many women find the slight hollow of the buccal

region that arises in their early 30s to be attractive

by creating a more sculpted appearance. Progressive

buccal volume loss will lend the appearance of poor

health, and in women can also be masculinizing.

During a fat augmentation procedure, the addition of

volume to the cheeks may create a relative buccal hol-

lowing, which should be addressed. The buccal area

can be approached from multiple entry sites, including

the midcheek or lateral canthal entry sites; alterna-

tively, a separate lateral commissure entry site can be

made for buccal access. Filling can progress rapidly as

above, with 0.1 cm3

per pass in every tissue plane.The

buccal area can sustain significant volume enhance-

ment without deformity, e.g., 3–8 cm3

per side.

Precanine fossa/nasolabial fold

As mentioned above, the objective of filling the pre-

canine fossa (the bony triangular depression deep to

the superior limit of the nasolabial fold and adjacent

to the nasal ala) and the nasolabial fold is not to elimi-

nate the fold but to provide improved transition from

the augmented cheek to the augmented upper lip.The

patient should be cognizant of this limitation so that

realistic expectations are established preoperatively.

The precanine fossa is infiltrated in the deep supra-

periosteal plane with approximately 2 cm3

of fat. The

nasolabial fold can be augmented with 2–3 cm3

of fat

along multiple levels using 0.1 cm3

per pass without

significant risk of deformity.These areas are addressed

from the midcheek entry point so the cannula will pass

perpendicular to the nasolabial fold.

Prejowl sulcus/anterior chin/labiomental

sulcus/labiomandibular fold

The prejowl sulcus is perhaps the most important area

in the lower face to address with autologous fat trans-

fer. Placement of fat along the prejowl sulcus will not


Fig.18.9 Fat injection of the inferior orbital rim.

(a) Demonstration of how placement of the index finger of the

nondominant hand is used to protect the globe and give

tactile feedback as to the cannula position. (b) Intraoperative

demonstration of the vector for approaching the inferior

orbital rim in a perpendicular orientation from the midcheek

entry site.Reprinted with permission from Lam SM,Glasgold

MJ,Glasgold RA.:Complementary Fat Grafting.

Philadelphia:Lippincott Williams & Wilkins;2007.

a

b


completely straighten a jawline that exhibits moderate

to marked jowling, but will significantly enhance any

facelift result.The prejowl sulcus should be thought of

as a three-dimensional cylinder that runs along the

anterior and inferior borders of the mandible.

Generally, 3 cm3

of fat are placed using 0.1 cm3

per pass

from an entry site just posterior to the prejowl sulcus,

typically about midway along the mandibular body.The

first 1 cm3

is placed deeply along the anterior madibu-

lar border.The second 1 cm3

is placed deeply along the

inferior mandibular border, and the third 1 cm3

is

placed at a medium-depth to transition between the

two. In patients with a deeper sulcus, larger volumes

will be needed to obtain the desired result. Additional

fat can be feathered into the anterior chin, labiomental

sulcus, and labiomandibular fold as needed. It is impor-

tant to emphasize that the degree of variable resorption

of fat in the anterior chin leads to less predictable

results in terms of chin projection than can be achieved

with an implant.Therefore, when the primary goal is

anterior chin projection, an alloplastic chin implant

is our preferred treatment option. Nevertheless, fat

transfer to the anterior chin/mental sulcus region can

accentuate the beauty of a youthful face by restoring

the inferior apex of the ideal heart shape previously

discussed.

POSTOPERATIVE CONSIDERATIONS

Postoperative care

At the end of the procedure, the patient does not

require any dressings, bandages, drains, or suture clo-

sures for the body or for the face. Icing of all recipient

sites will help mitigate postoperative edema. After the

first 48–72 hours, the patient may ice the recipient

areas as they would like. Sleeping with the head

elevated for the first several days may also aid in reduc-

tion of edema. Reducing dietary for the first several

weeks after surgery may also lessen edema.The patient

should refrain from strenuous activity so as not to

exacerbate and prolong edema unnecessarily. The

patient can return to a modified exercise regimen after

the first week and should slowly progress toward a

full, standard program, verifying all the while that

edema does not worsen with that activity.There are no

restrictions on activity for harvested areas, except for

not submerging the incisions for a week.

Postoperatively, patients often complain of a dull ache

and soreness in the donor areas that exceeds any dis-

comfort felt in their face. However, there may be some

degree of tenderness and tightness in the face, particu-

larly in the malar region. Occasionally, patients can feel a

flush sensation in the malar area during the first post-

operative week, which can be ameliorated with icing.

Ecchymosis and edema are most pronounced over

the first two postoperative weeks. During the first

week, the patient may appear grossly disfigured, which

will be proportionate to the amount of fat transferred

and the number and extent of concurrent rejuvenation

procedures. Ongoing changes will be evident postop-

eratively for several months, and it should be empha-

sized to the patient that what he or she is seeing is

normal and expected due to the dissipation of edema.

Educating patients preoperatively and reviewing the

expected changes postoperatively are helpful for

the patient to have the appropriate understanding of

the changes they are seeing as swelling subsides.

Management of complications

The area most susceptible to complications is the peri-

orbital region.The conservative policy of fat enhance-

ment (‘hitting doubles’) previously outlined should be

followed so as to minimize the occurrence of prob-

lems. In order to correct a complication, the surgeon

must correctly identify the problem.This section will

outline the unique types of problems that occur with

fat grafting and how to treat each specific entity. The

types of complications can be classified as follows:

lumps, bulges, overcorrection, and undercorrection.

Lumps

A lump is a soft discrete contour deformity that arises

when too much fat is transplanted to a specific locus or

placed in an imprecise fashion. Although steroid injec-

tions have been attempted to manage this problem,

they are generally not very effective. An incision with

direct removal of the offending lump often must be

undertaken. Although uncommon, visible lumps are

most apt to occur along the inferior orbital rim. If a

lump from the region of the lower lid is to be




Fig.18.10 (a) Preoperative photograph. (b) Following upper lid blepharoplasty and periorbital fat transfer, the patient

presented with visible lumps in the inferior orbital rim. (c) Direct excision of transferred fat to correct contour. (d) Postoperative

photograph showing correction of the complication.Reprinted with permission from Lam SM,Glasgold MJ,Glasgold RA.:

Complementary Fat Grafting. Philadelphia:Lippincott Williams & Wilkins;2007.

b

d

a

c



removed, an incision in the tear trough, following

along the inferior orbital rim, heals very well and also

allows for removal of excess skin (Fig. 18.10).

Bulges

A bulge represents a more oval-shaped contour defor-

mity that is associated with fibrotic tissue, which can

be palpated when pushing against the bony inferior

orbital rim. It will most likely occur in the central to

lateral portion of the inferior orbital rim. The exact

cause of this is not known, but we have only encoun-

tered it when the inferior orbital rim was injected

from a lateral canthal entry point. Dilute concentra-

tions of triamcinolone acetonide (5–10 mg/cm3) can

be used in most circumstances to correct this condi-

tion. Higher concentrations can be used progressively

at monthly intervals as needed, taking into considera-

tion the potential for creating a depression. Having

changed technique so that the fat is always layered

perpendicular to the inferior orbital rim, this problem

has virtually been eliminated.

Overcorrection

Overcorrection should be avoided if the conservative

policy of ‘hitting doubles’ is followed. Early in the post-

operative period, patients may not uncommonly feel

they are overcorrected. Due to the degree of and pro-

longed nature of swelling, we recommend waiting at

least 6 months before deciding that there is too much

volume and attempting to reduce it.Although rare, this

is most likely to happen in the inferior orbital and malar

regions, and will tend to be exaggerated when the

patient smiles. An 18-gauge Klein–Capistrano micro-

liposuction cannula (HK Surgical, Inc., San Clemente,

CA) can be used to reduce the excessive volume.

Undercorrection

Undercorrection is the most favorable complication to

encounter, as it can be easily corrected with an addi-

tional touch-up session. As autologous fat transfer

involves a free graft, there will be variable resorption

of the fat. The patient should be counseled preopera-

tively about the possibility of a touch-up procedure, so

that they are prepared for it. Areas that required large

initial volumes due to significant volume deficiency

are more likely to need additional fat added at a second

procedure. Generally, the surgeon should resist

returning to the operating room for intervention ear-

lier than 6 months, in order to provide ample time for

edema to settle and any graft resorption to occur. At

the 6-month juncture, the amount of volume loss (if

any) can easily guide the surgeon on how much to

infiltrate so as to provide appropriate correction.

CONCLUSIONS

Autologous fat transfer is predicated on a new aes-

thetic paradigm that envisions a major component of

the aging process as volume loss.The strategy outlined

above advocates a conservative policy of volume

enhancement that can easily be combined concur-

rently with other types of rejuvenative procedures,

e.g., blepharoplasty, facelift, skin resurfacing, etc.

Unlike some proponents of fat grafting, we do not

strictly adhere to the philosophy that this is the only

correct method of facial rejuvenation. A judicious

combination of therapies can often provide the most

satisfying aesthetic outcomes.


abdominoplasty 139

ablative resurfacing

in dermatoheliosis 118

vs nonablative skin resurfacing 51–2

Accent RF system in cellulite 145

Accreditation Association of Ambulatory

Healthcare (AAAHC) 2, 3

acne excoriée 95

acne scarring 17, 18, 24, 89–100

age of scars and active acne 90–1

cytotoxic therapies 91–2

definition and classification 89–90, 89

fillers 97–8, 97–8

fractional thermolysis in 54

hypertrophic 99

hypopigmented cheek scars 95

incisional surgery 91–2, 96–7

keloidal 99

management 91

nonablative therapy 91–2, 94–5

partially ablative therapy 95

pathogenesis 91

resurfacing 91, 92–4

acne vulgaris 22, 31, 69–85

d-aminolevulinic acid (ALA) 78

and blue light 79

and IPL 79

and PDL 79–80

and polychromatic visible light 79

and red light 78–9

and red light diode laser 79

clinical experience 71

incidence 69

indocyanine green 80–1

infrared lasers 80, 81–4, 81

1450 nm 81–2

1450 nm laser in combination 82–4

1540 nm 84

CoolTouch 1320 nm 84

isotretinoin use in 81

KTP laser 75–6

laser 75–7

laser choice 71

lesion types 69

pathogenesis 69–71, 70

pathophysiological features 69

patient encounter 71

patient screening 71

photodynamic therapy 78–81, 177–8, 179, 181

photoinactivation with visible light 72–5

blue light 73

combination blue and red light 73–4

intense pulsed light 74

pulsed light and heat 74–5

UVA/UVB 72–3

yellow light 74

pilosebaceous units, targeting 78–85

porphyrins in 71–2, 72

pulsed dye laser 76–7

585 nm 76–7

595 nm 77

radiofrequency 84–5

SmoothBeam and Thermage 84

ThermaCool device 84

targeting 77

see also acne scarring

actinic cheilitis 17

actinic keratosis 17, 42

actinic lentigines 42, 112–17, 113–14

actinic purpura 122

activation of laser, inadvertent 7

acyclovir 42

aesthetic skin rejuvenation (ASR) 31–44

age spots 42, 112–17, 113–14

ageless beauty 13

aging face 11–16

age specific features 12

analysis 12–13

chin position 15–16

chronological aging 11, 11

definition 11

features 11–12, 12

morphological aging 11–12, 11

non-age-specific features 12

perioral region 16

periorbital region 16

skin in 14

volume loss 14–15, 15

airborne contaminants, laser-generated 5–6

Alloderm 185

alpha-hydroxy acids, topical 19

American Association for Accreditation of

Ambulatory Surgery Facilities (AAAASF) 3

American National Standards Institute

(ANSI) 2, 3, 4, 7

d-aminolevulinic acid

(5–aminolevulinic acid; ALA) 59, 59, 60, 173

in acne 78–80

anesthesia, safety recommendations 7

angiofibromas 17

antibiotics, prophylactic systemic 20

antioxidants, topical 19

Aquaphor 27

argon lasers, hazards 5

Arnica Montana C5 192

Artecoll 186–7

arteriovenous malformations 126, 131

Aura KTP laser 76

Baker–Gordon peel 93

basal cell carcinomas 17, 40

Bell’s palsy 192

beta-hydroxy acids, topical 19

biological hazards 4–5

biophotonics 33–4, 34, 35, 38

biopsy punch in acne scarring 97

birthmarks, vascular 125

bleomycin 129

blink reflex 4

Blu-U 73

Botox 181–2, 184, 192, 195, 196, 202

dosages 193

botulinum neuromodulators 181–3

botulinum toxin 20, 181–6

biological materials as injectable implants 183–6

collagen 183–4

dermal matrices 185–6

historical perspective 183

hyaluronic acid 184–5

type A dilution and injection technique 191–2

see also botulinum toxin/filler combined use

botulinum toxin/filler combined use 191–202

forehead 195–6, 196

injection techniques 193–5

midface 196–200, 198–200

neck 201–2, 202

perioral area 200–1, 201

periorbital area 196, 197–8

Bowen’s disease, photodynamic therapy in 179

BURANE XL Er:YAG laser 38

burns 5, 8

Candela longer pulsed dye laser

in leg telangiectasia 162

Candida infections 20

candidiasis, vaginal 18, 20

capillary vascular malformations 126

treatment 129–30

capillary angioma 126

Captique 97, 184, 196, 200

carbon dioxide laser, hazards of 4–5

carbon dioxide laser resurfacing 17–28

in acne 92, 93

complications 21–2, 22

indications 17–18

infections 22, 22

Index

Note: Page references in bold refer to Figures and Tables

Index Carniol-8028.qxd 8/23/2007 10:36 AM Page 219

laser development 17

laser surfacing 20–1

patient selection 18, 19

pigmentary abnormalities 23–6, 23

postoperative care 21

preoperative care 19–20

procedure 19–21

special considerations 26–8

cavernous hemangioma 126

Cellulair 202

cellulite 143–6

formation 143–4

monopolar radiofrequency 145–6

TriActive 145

Velasmooth 144–5, 145

cervicofacial rhytidectomy 103

cheilitis, actinic 17

chemical peel 23, 26, 31, 103

in acne scarring 93

chickenpox 31

chin position 15–16

chromophones, cutaneous 47

classification

of hazards 2–4

of lasers 1–2

ClearLight 73

ClearTouch system 74, 75, 75

Coherent UltraFine Er:YAG laser 36, 36

collagen 183–4

induction therapy in acne scarring 95

complementary fat grafting 205–17, 206

anatomy 207–8, 207–9

complications 215–17

bulges 217

lumps 215–17

overcorrection 217

undercorrection 217

consultation 208–10

donor harvesting 210–11

fat infiltration 212–15

anterior cheek 213

buccal 214

inferior orbital rim 212–13

lateral cheek 214

nasojugal groove 213

precanine fossa/nasolabial fold 214

prejowl sulcus/anterior chin/labiomental

sulcus/labiomandibular fold 214–15

superior orbital rim/brow 213

fat processing 211–12

operative technique 210–15

postoperative care 215

postoperative considerations 215–17

preoperative considerations 207–10

recipient site anesthesia 212

complications, lasers and light sources 45–50

causes 46

failure to anticipate, recognize and treat

postoperative complications 48–9

failure to recognize the presenting clinical

condition 48

failure to refer 49

failure to screen and inform patients 49

incorrect choice of laser or light source 47, 48

lack of operator knowledge and experience 46–7

computerized pattern generator (CPG)

scanning devices 17

ConBio CB Erbium/2.94 36

condyloma lata 173

CoolGlide laser 167, 168–9

CoolScan 27

CoolTouch II 61

CoolTouch Varia 167–8

cornea, injury to 4

corneal protectors 5

Cosmoderm 97

Cosmoplast 97, 200

crow’s feet 182

cryotherapy in solar lentigines 114

Cushing’s syndrome 140

cutaneous injury 5

cutaneous T-cell lymphoma 173

Cyanosure CO3 laser 38O.K. or Cynosure

Cymetra 185

Cyngery 170

Cynosure longer pulsed dye laser

in leg telangiectasia 162–3

cystic hygromas 126

depigmentation 23–4, 23

dermabrasion 31

in acne scarring 93

Dermadeep 187

DermaK Er:YAG laser (Sharplan) 37

Dermalive 187

dermatitis

atopic 173

contact 22, 24

dermatoheliosis 17, 18, 117–19

diazepam20

dyschromia, laser hair removal and 138, 138

Dysport (Rexolan) 181, 192

ectropion, postoperative 42

electrical hazards 5

electromagnetic interference 6

electro-optical synergy (ELOS) 61–2, 61

EMLA 20

environment of care 8–9

Er:YAG lasers 17

in ablative resurfacing for acne scarring 92–3

short-pulse Er:YAG systems 35–6, 36

dual-mode Er:YAG system 36–7

dual-mode, different laser type 36–7

same laser type, variable pulse duration 37

variable-pulse Er:YAG systems 38

erbium 33, 33

erbium laser aesthetic skin rejuvenation 31–44

avoidance and treatment of complications 41–2

clinical aesthetic applications 39–41

clinical dermatological applications 38–9, 38

commercially available lasers 34–8

erbium laser light—tissue interaction 33–4, 35

laser evolution 32

laser radiation safety 41

patient selection and perioperative management 41–3

physical properties 32–3, 34

techniques 41

cutaneous ablative surgery 41

deep LASR 41

dry erbium 41

medium LASR 41

superficial LASR 41

see also Er:YAG lasers

erbium:yttrium alumium garnet lasers

see Er:YAG lasers

excimer lasers, hazards 4

famciclovir 20, 42

fat as autologous filler for acne scarring 98

see also complementary fat grafting

fillers

in acne scarring 97–8, 97–8

classification 193

cross-hatching techniques 193

fanning technique 193

fat 98

injectable 192–3

linear threading technique 193

serial puncture technique 193

soft tissue 183, 183

see also botulinum toxin/filler combined use;

complementary fat grafting

fire extinguishers 8

fire hazard 6–7

fire, preparation for 8

fire triangle 6–7

Fitzpatrick skin types 14

flashlamp-pumped dye laser (FLPDL) 25

fluconazole 20

5–fluorouracil 25, 26

footprinting 23

fractional carbon dioxide resurfacing 27–8

fractional photothermolysis (FP) 51–2

fractional resurfacing 27–8

in acne scarring 95

in dermatoheliosis 118–19

in solar lentigines 116

fractional thermolysis 27

Fraxel laser 116–17, 117, 118–19

GentleYAG laser 167

Glasgold Fat Transfer Set 212

Glogau wrinkle scale 14

glucocorticosteroids, intralesional 25

hair removal, unwanted 135–8

candidate selection 135

complications 137–8, 138

consultation 135–6

future 138

photodynamic therapy 178

preoperative procedure 136

procedure 136–7, 137

Harmony laser 167

hazards

biological 4–5

classification 2–4

electrical 5

fire 6–7

non-beam-related 5–6

training 9

Hebra 31

hemangiomas 125–6, 157

cavernous 126

congenital 125

infantile 125, 127–9, 127, 128

treatment 127–9

heme biosynthesis pathway 173, 174

herpes simplex virus (HSV) 18, 20, 42

post carbon dioxide laser resurfacing 46

220 Index


high-intensity focused ultrasound (HIFU)

in lipolysis 148

Ho:YAG lasers, hazards 5

Hyalform 184

Hyalform Fine Line 184

Hyalform Plus 184

hyaluronic acids 184–5, 193, 194

hydroquinone,

pretreatment with 19

Hylaform 97

Hylaform plus 97

hyperpigmentation 18, 19, 26

hypertrophic scarring 24, 26

in acne vulgaris 99

after carbon dioxide laser burn 47

formation 41

after long-pulse YAG laser treatment 47

hypopigmentation 18, 23, 24

in acne scarring 95, 97

imiquimod 129

indocyanine green in acne 80–1

infections 22

causative agents 22

informed consent 49

insurance 3–4

intense pulsed light (IPL) systems 23

in acne scarring 94

in acne vulgaris 79

in dermatoheliosis 119

in photorejuvenation 57, 60

in solar lentigines 114

in striae distensae 140–1

interferon therapy 129

Isolagen 186

isotretinon 41–2

Jessner’s peel 23, 26

in acne scarring 93

Joint Commission (Joint Commission on

Accreditation of Healthcare

Organizations; JCAHO) 2, 3

Juvederm 97, 184, 187, 196, 197, 200

keloid scarring 41, 99, 187

Kenalog 25

keratosis

actinic 17, 42

seborrheic 17, 39, 40, 42

ketorolac 20

krypton laser in solar lentigines 114

KTP lasers 76

hazards 5

in acne scarring 94

in acne vularis 75–6


in poikiloderma of civatte 120

in skin tighening 151

laser-assisted skin rejuvenation

(LASR) 32, 41

laser-generated electromagnetic interference 5

laser history 45

laser plume 5–6

laser smoke evacuator 6

lichen planus 18

lidocaine 20

lipolysis 146–8

low-level laser 148

Nd:YAG laser 147

ultrasound 147–8

liposuction 107, 139

liver spots 42, 112–17, 113–14

Lumenis One laser 167

lung, shock 8

lupus vulgaris 173

LuxVO (Palomar) 74

lymphatic malformations 126, 131

Lyra laser 167, 169

maximal permissible exposure (MPE) 5

Medlite laser system 113

melasma 53

MEND (microscopic epidermal necrotic debris)

formation 116, 116, 121

Menderma gel 25

meperidine 20

mequinol 112

methicillin-resistant

Stapylococcus aureus (MRSA) 20

microablative skin resurfacing 51–2

microdermabrasion

in acne scarring 94

in striae distensae 140

microlaser peels 116

microscopic treatment zones (MTZs) 143

microthermal zones (MTZs) 52

midazolam 20

milia formation 22

monopolar radiofrequency skin

tightening 104–7, 105

background 104

clinical effects 105–6

newer applications and additional uses 106–7

side-effects and limitations 106

treatment parameters 104–5, 105

MultiClear system 142, 142

mupricin, nasal 20

Mydon laser 167

Nd:YAG lasers

hazards 5

in leg telangiectasia 159–62, 166–7, 170

in lipolysis 147

Q-switched, in solar lentigines 112–13

in skin tightening 150–1

near-infrared skin tightening 107–9

background 107–8

clinical effects 108–9

future directions 109

side-effects and limitations 109

treatment parameters 108

neck resurfacing 26–7

Nexgen pixel 36

Nlite System pulsed dye laser 61, 76

nominal hazard zone (NHZ) 5

nonablative skin resurfacing 51

vs ablative skin resurfacing 51–2

in acne scarring 91–2, 94–5

long-wavelength lasers and light

sources for collagen stimulation 59–62

for photorejuvenation 52–62

skin tightening 62–5, 63, 64, 65

see also photodynamic therapy

non-beam-related hazards 5–6

nonerythematosus scars 26

nonsurgical tightening 103–9

monopolar radiofrequency 104–7, 105

near-infrared skin tightening 107–9

NSAIDS 22

Oasis 186

Occupational Safety and Health

Administration (OSHA) 2

optical radiation hazard 4

pacemakers 6

PASS mnemonic 8

pathophysiology of aging 12

Pearl fractional laser 27

perifollicular hypopigmentation

of acne scars 97

perioral region in aging face 16

periorbital region in aging face 16

Perlane 184, 197, 200, 200, 201

phenol 31

phenol peel 93

photoaging 17, 18, 111–22

photochemotherapy 24

photodynamic therapy 173–9

acne 78–81, 177–8, 179, 181

clinical applications 175

future 179

hair removal 178

lasers and light sources 174–5

mechanism 173–4

photorejuvenation 59, 59, 60, 175–7, 176

sebaceous gland hyperplasia 177–8

side-effects 179

photofacial technique 23

photohyperthermia selective 146–7

photorejuvenation 52–62

intense pulsed light 53–5, 55, 57, 60

laser or visible light technology 52–3

photomodulation 56–8

potassium titanyl phosphate 55–6, 58

pulsed dye laser 53, 55

photoprotection, preoperative 19

photothermolysis, selective 135

pigmentary abnormalities 23–6

plasma resurfacing

in acne scarring 94

poikiloderma of civatte 119–21, 121

Polaris WR, skin tightening and 150

polycarbonate safety glasses5

portwine stains 128, 130, 157

potassium titanyl phosphate (KTP) lasers

see KTP lasers

pregnancy, striae distensae in 140

Profile laser 167

Propionibacterium acnes 69, 71–7

see also acne scarring; acne vulgaris

Pseudomonas aeruginosa 22

psoriasis 18

pulsed-dye laser

in acne scarring 94

in acne vulgaris 76–7


in photorejuvenation 53–5, 55, 57, 60

in poikiloderma of civatte 120, 121

Putrtox 181

Index 221


Q-switched alexandrite laser

in solar lentigines 113–14

Q-switched lasers

in acne scarring 95


Q-switched Nd:YAG laser (QSNd:YAG laser)


Q-switched ruby laser (QSRL)


Quantel Medical Multipulse mode 169–70

Radiesse 97, 186, 195, 197, 198, 198, 199

ReFirme in skin tightening 152, 152

regulations 2

Reloxin 181

repigmentation 24

Restylane 97, 184, 185, 187, 197,

198, 200, 200, 201

Restylane Fine Lines 184, 196, 200

Restylane Touch 196

Restylane Vital 196, 202

resurfacing cosmetic units 26

retinal hazard region 4

retinoic acid 111, 112

retinoid, topical, preoperative 19

Reviderm intra 186

rhytids 18, 18, 20, 21

rosacea 125, 131–2

safety, laser 1–9

scar resurfacing 26

scarring, following laser surgery 24–6

Sciton Contour 37, 37

Sciton laser 21

scleroderma 18

sclerotherapy 130–1

leg telangiectasia 157, 168, 169, 169, 170

Sculptra 186, 195, 197

sebaceous gland hyperplasia,

photodynamic therapy 177–8

seborrheic keratosis 17, 39, 40, 42

shock lung 8

silicone 187, 187

as filler for acne scarring 97–8

skin cancer 173

skin rejuvenation, modalities 31–2

skin rolling or needling in acne scarring 95

skin tightening 148–52

infrared light-based 65, 65, 151, 152

Nd:YAG laser 150–1

nonablative rejuvenation 62–5, 63, 149

radiofrequency-based 62–5, 63, 64, 149–50, 150

smallpox 31

SmartEpilII laser 167

SmoothBeam 61

soft tissue fillers

droplet technique 188

linear threading 188

serial puncture technique 188

techniques 188

see also botulinum toxin

SoftForm 187, 188

solar elastosis 51, 117, 118

solar lentigines 42, 112–17, 113–14

squamous-cell carcinoma 17

steroid-induced atrophy 24

Stratasis 186

strawberry angioma 126

stretchmarks 139–43

striae alba 140, 141, 142

striae distensae (stretchmarks) 139–43

intensed pulsed light 141

mid-infrared 142–3


ultraviolet 141–2

striae rubra 140

Sturge–Weber syndrome 129

subcision in acne scarring 96–7, 96

sunspots 42, 112–17, 113–14

sunscreen use, preoperative 19

surgical masks 6

SurgiLift 196, 202

Surgisis 186

synthesized bioactive fillers 186

synthetic nonresorbable polymers 186–8

implantable 187–8

injectable 186–7

syringomas 17

system lupus erythematosis 18

telangiectasia 24

facial 131–2, 132

PDL in 120

see also telangiectasia, leg

telangiectasia, leg 157–71

combination/sequential 595 nm

PDL and 1064 nm Nd:YAG 170

CoolGlide 168–9

CoolTouch Varia 167–8

diode lasers 163–4

histology 159

intense pulsed light 164–6, 164, 165

KTP and frequency-doubled

Nd-YAG lasers 159–62

lasers and light sources 160–1

Lyra 169

Nd:YAG laser 166–7

pathogenesis 157–9


Quantel Medical Multipulse mode 169–70

Vasculite 167

telangiectatic matting ™ 157

ThermaCool TC 64, 103, 104–7

skin tightening and 149–50

Thermage 196, 201, 202

Titan (Cutera) 103, 107–8, 109

tobacco smoking 19–20

training in safety 9

tretinoin, topical, preoperative 19

TriActive laser

in cellulite 145

in lipolysis 147

trichoepitheliomas 17

trypsin epidermal grafting in acne scarring 97

Tummy by Thermage treatment 107

UltraPulse carbon dioxide laser 17, 20

UltraShape System Ltd in lipolysis 147

Ultrasoft 187, 188

V Beam 25

valacyclovir 20, 42

varicella scars 24

vascular malformations 126, 128

VascuLight 25

Vasculite laser 167

Vbeam 61

Velasmooth 144–5, 145

venous malformations 126, 130–2

venular vascular

malformations 126, 129–30, 130

Verapulse long-pulse (VLP)

Nd:YAG laser in solar lentigines 113

Verapulse Q-switched (VQS)

Nd:YAG laser in solar lentigines 113

vitiligo 18, 24, 141, 173

volume loss, facial 14–15

waste disposal 5

wrinkles 17

ystrium aluminum garnet (YAG) 32–3, 33

Zeno 85

Zyderm I and II 183

Zyplast 183–4, 185

222 Index


clinical_procedures_in_laser_skin_rejuvenation__series_in_cosmetic_and_laser_therapy_

Documents

laser therapypublished

cutaneous laser surgery

journal of cosmetic

clinical dermatology

david goldberg

textbook of liposuction

handbook of cosmetic

london w1p