the use of infrared radiation in the treatment of skin laxity
TRANSCRIPT
Correspondence: Pietro Gentile, Department of Plastic and Reconstructive Surgery, University of Rome Tor Vergata, Oxford Street, Rome 00186, Italy. E-mail: [email protected]
(Received 2 April 2013 ; accepted 17 October 2013 )
Introduction
The continuous research to improve the quality of living standards makes the fi elds of medicine and surgery extremely interesting for plastic surgeons due to patients ’ functional, psychological and social issues (1). The use of lasers and lights has partially revolutionized the techniques for the rejuvenation and forming of skin tissues. The use of this kind of technology has allowed cosmetic surgery operations without lancets. Lasers and lights employed in cosmetic surgery determine ablation, contraction and stimulus in skin tissues. In this study we have examined the use of infrared lights in treating face and body skin laxity. One of the surgeon ’ s main issues when facing a patient suffering from skin ageing and the psychological problem of the accep-tance of himself/herself is to clearly point out the limits and real possibilities of these techniques. The use of infrared radiation today led us to treat patients
who would never consider the use of lancets or who would have a high surgery risk (2). Every single clinical case must be examined and evaluated in advance. During the operating phase, accurate protocols must be used according to the needs of each single case. By using infrared radiation, we are able to treat a vast body section, thus obtaining remarkable aesthetic advantages. The selectivity of the wavelength gives us the opportunity of treating vast body areas, preserving the underlying “ noble ” structures (3).
In this study, we report the experience and procedures carried out in the Department of Plastic and Reconstructive Surgery at the Hospital San Camillo-Forlanini between 2007 and 2009. We describe the indications and the techniques most fre-quently used: face lift, lifting of neck and shoulders, eyebrow lift, thigh lift, abdomen lift and buttocks lift. We have also analysed immediate and long-term post-treatment complications and case studies.
Journal of Cosmetic and Laser Therapy, 2014; 16: 89–95
ISSN 1476-4172 print/ISSN 1476-4180 online © 2014 Informa UK, Ltd.DOI: 10.3109/14764172.2013.864199
ORIGINAL RESEARCH REPORT
The use of infrared radiation in the treatment of skin laxity
MARCO FELICI 1 , PIETRO GENTILE 2 , BARBARA DE ANGELIS 2 , LIVIA PUCCIO 1 , ALDO PUGLISI 1 , ALDO FELICI 1 , PAMELA DELOGU 2 & VALERIO CERVELLI 2
1 San Camillo Hospital, Plastic Surgery, Rome, Italy and 2 Department of Plastic and Reconstructive Surgery, University of Rome Tor Vergata, Rome, Italy
Abstract Background: Cosmetic surgery and medicine are extremely interesting fi elds for a plastic surgeon. Lasers and lights determine ablation, contraction and regenerating stimulus in skin tissues. The aim of this study is to examine the use of infrared lights in treating facial and body skin laxity. Methods: Between 2007 and 2011, in the Department of Plastic and Reconstructive Surgery at the Hospital San Camillo-Forlanini, 303 patients were enrolled in the study and underwent laser therapy. The laser operates in wavelength from 1100 to 1800 nm. The treated areas are: face, neck, eyebrows, abdomen, legs and buttocks. Results: We have noticed no systemic complications. A case of a patient with a three days lasting erythema on both lower eyelids caused by laser therapy healed without any pharmacological therapy. Neither hyper- nor hypopig-mentation of the skin was found. The satisfaction degree of patients has been: facial, neck and eyebrow lifting “ very satisfactory ” for 70% of the patients, “ satisfactory ” for 10%, “ unsatisfactory ” for 20%; for the other areas it was “ very satisfactory ” for 40%, “ satisfactory ” for 20% and “ unsatisfactory ” for 40%. Conclusion: The use of infrared radiation represents a valid alternative to surgical lifting, but cannot replace it. The infrared light technique used has turned out to be useful in contrasting skin laxity of the face and other parts of the body. The absence of scars and surgical risk makes this technique useable for a large number of patients.
Key Words: aesthetic lasers , infrared radiation , skin laxity
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Materials and methods
Patients
Between 2007 and 2011, in the Department of Plastic and Reconstructive Surgery of the Hospital San Camillo-Forlanini, 303 patients have been treated using infrared radiation with a wavelength ranging from 1100 to 1800 nm (Titan product by Cutera.) (Table I).
The areas we dealt with are: face, neck, eyebrows, abdomen, legs and buttocks.
The age range was from 35 to 85, with an average of 52. In 200 cases the treatment regarded face (Figures 1, 2) and eyebrows, in 125 cases the neck (Figures 4, 6), in 10 cases the abdomen (Figure 5), in 7 cases the legs and in 8 cases the buttocks (Figure 3).
For the facial treatment, four phases were carried out, using a J range between 38 and 44. For the eyebrows we employed only 34 – 35 J, since the tissue is rather thin. For the abdomen, legs and buttocks, four phases of 42 – 50 J were needed. The treatment protocol consists of a fi rst application and a second after 2 months. The recommended maintenance is twice yearly using the same parameters.
The highest number of cases treated with infrared radiation concerned the face. The anatomic limits to be taken into consideration are: anteriorly 1 cm below orbit border, posteriorly the nasolabial folds,
inferiorly the jaw and posteriorly the pre-auricular region. A preliminary evaluation of the patient is still fundamental, completing a thorough anamnesis.
Criteria of exclusion
Patients having permanent fi ller or prosthetic mate-rials implanted have been excluded from this treat-ment because the rise in derma temperature may cause peri-prosthetic reactions. We also excluded patients that were treated with photosensitizing drugs (antibiotics, cortisonics, antidepressants), which could cause hyperpigmentation. Patients who were affected by herpes simplex were excluded just prior to undergoing treatment as this pathology could extend to the entire treated area – patients recently operated in these regions could suffer from
Figure 1. (A) Pre-operative in frontal projection, (C) in 3/4 right projection, (E) in lateral left projection, (B) Post-operative after 7 months in frontal projection, (D) Post-operative after 7 months in 3/4 right projection, (F) Post-operative after 7 months in lateral left projection.
Table I. Region of the body treated.
Region of the body treatedNumber of treatments Joule used
Face and brow 200 38 – 44; 34 – 35Neck 125 42 – 50Abdomen 10 44 – 48Legs 7 42 – 46Buttocks 8 44 – 50Total of patients 303
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hyperpigmentation. The presence of suitable con-nective tissue was accurately examined, since the infrared radiation generates a concentration of elas-tin and collagen and its exiguous presence may determine an absence of results. There are no inter-actions or contraindications in treating those areas that have previously undergone hyaluronic acid treatment, collagen or botulinic toxin, if they have been implanted at least two weeks before the infra-red radiation treatment.
Anatomical area of treatments
The eyebrow area reacts extremely well too. Ten strokes with a 24 – 35 J intensity are applied to the area that goes from the temporal front suture to the temporal zygomatic one, 1 cm from the eyebrow up to the scalp. The application protocol is identical to that used for the face. We may obtain up to 1 – 2 cm of lifting.
Contrasting results have been obtained when treating areas other than face. The infrared light acts, as we have previously illustrated, only at a cutaneous level, since it is ineffective at a subcutaneous and muscular level, and on the structures involved in the laxity of those areas.
During the preliminary examination of the patients, apart from using the previously mentioned criteria, we also excluded those affected by localized lipodystrophy in the regions needing treatment. The protocols employed consist of four applications in the medial area of the thighs using a 42 – 46 J intensity, four applications in the abdominal region with a 44 – 48 J intensity and four applications with a 44 – 50 J intensity for the buttocks. The treatment is repeated after 2 months. To maintain the results, another intervention is required after 6 months.
Informed consensus
The fi rm producing the equipment gave us an informed consensus in which the following compli-cations are listed: uneasiness (after treatment there may be burns, bruises, blisters and bleeding in the treated areas – this may recover in an estimated time of one to three days. As in all skin damages it is possible that the injury may never recover com-pletely); infection (a rare possibility when proceed-ing on skin, even if an appropriate cure should prevent it); and changes in pigmentation (during the period of recovery there could be a remote possibility that the treated region assumes a lighter
Figure 2. (A) Pre-operative situation in frontal projection, (C) in lateral right projection, (E) in lateral left projection, (B) Post-operative after 7 months in frontal projection, (D) Post-operative after 7 months in lateral right projection, (F) Post-operative after 7 months in lateral left projection.
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Figure 3. (A) Pre-operative situation in back projection, (C) in lateral left projection, (E) in lateral right projection, (B) Post-operative after 2 months in back projection, (D) Post-operative after 2 months in lateral left projection, (F) Post-operative after 2 months in lateral right projection.
Figure 4. (A) Pre-operative situation in lateral right projection, (C) in lateral left projection, (B) Post-operative after 9 months in lateral right projection, (D) Post-operative after 9 months in lateral left projection.
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or a darker pigmentation compared to the sur-rounding areas. Usually this is a short term effect, but in rare occasions the results could be perma-nent); scars (the insurgence of a scar is extremely rare, but not impossible); eye exposure (it is abso-lutely necessary to wear protective glasses for the entire length of the treatment in order to protect eyes from eventual wounds).
Procedures
The treatment in our experience is well tolerated by patients who need neither local anaesthetic (lido-caine ointment) nor pharmacological sedation.
The duration of the treatment is relatively brief (for example about 40 min for the face). It is nec-essary to cleanse the skin to remove cosmetics, lotion and oil; both patient and technician must wear the appropriate protective goggles. The treat-ment is carried out by using instrument with a rect-angular contact surface of a variable dimension. The procedure is carried out through a series of single applications.
The single application is composed of three phases: a one second pre-cooling, followed by the
irradiation of the infrared light and a fi nal post-application cooling.
In order to better vehiculate the cooling, a very thin layer of transparent gel for ultrasonography is used. This is the cooing vehicle that avoids possible burns as a perfect adhesion of the instruments ’ contact surface to the skin is fundamental. At the end of the treatment a rash or a swelling may appear on the treated areas. These are short-term effects and not at all severe.
Detail about radiation source
Titan ’ s radiation source generates energy from 1100 to 1800 nm with a range of fl uence 5 – 65 J/Cm 2 and spot size 10 � 15 mm or 10 � 30 mm. The treatment cycle consists of 4 – 10 s and the device has audible tone and led indicator.
Results
The satisfaction degree has been: for face, neck and eyebrow lifting “ very satisfactory ” for 70% of the patients, “ satisfactory ” for 10%, “ unsatisfactory ” for 20%; for the other areas it was “ very satisfactory ”
Figure 5. (A) Pre-operative situation in frontal projection, (B) Post-operative after 11 months frontal projection, (C) Detail of pre-operative situation in frontal projection, (D) Detail of post-operative after one day in frontal projection.
Figure 6. (A) Pre-operative situation in frontal projection, (B) Post-operative after 5 months frontal projection.
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for 40%, “ satisfactory ” for 20% and “ unsatisfactory ” for 40%. The data reported shows that treatments on the face, brow and neck were more satisfactory than the other areas treated.
We wondered whether or not the degree of patient satisfaction was infl uenced by the region of the body treated. Entries in the table show that the best out-comes were for face, brow and neck. The p -value was used for statistical analysis (Table II).
This means that the probability of achieving the best outcome for face, brow and neck is smaller than 1%. Therefore, it is very likely ( � 99%) that treat-ments carried out on the face, brow and neck are very satisfactory.
These data contrast with the clinical assessment according to which only 5% of the patients had a disappointment about the result. Probably the high cost coupled with the excessively high expectations in this treatment has shown this difference. The treat-ment in other parts of the body has determined improvements that resulted in a lower satisfaction: in fact the application excluded the involvement of lypodystrophic problems and muscular hypotonia, probably even more unaesthetic than treated skin laxity. According to our personal experience, we have not noticed any systemic complication. However, at a localized level, we observed an erythema and a rash in 70% of the patients 2 h after the treatment. There was one case where a patient who was treated on the face had an erythema on both lower eyelids that lasted for about three days but we observed the resolution of it without pharmacological therapy. Neither hyper- nor hypopigmentation of the skin was noticed, thanks to an accurate anamnesis of the patients and the consequent exclusion of those undergoing treatment with potentially photosensitiz-ing drugs. If we apply the protocols for selecting potential candidates, following an accurate anamne-sis and a preventive evaluation of the patients, the treatment may be considered extremely safe, also considering the very low percentage of local compli-cations and a total absence of systemic ones.
Discussion
The fi rst luminous radiation was used in the medical fi eld by Maiman in (4) 1960: it consisted of a ruby rod that beamed a light at a wavelength of 694 nm. Since then other lasers have been built. The most important ones include the yttrium garnet laser which was drugged with neodymium aluminium (Nd:YAG) in 1961, the Argon laser in 1962 and the Carbon Dioxide (CO 2 ) one in 1964 (5). In 1965 Goldman (6) reported having used the ruby laser to remove tattoos with minimal resulting scars. Subsequently, the Nd:YAG laser has been employed to treat tattoos and superfi cial vascular malforma-tions. The Argon laser has been used for the fi rst time in vascular damages in the mid 60s, but its use was limited due to the high risk of scaring. Only in 1983, after the publication of the theory of the selective photothermolysis, a wider understanding of interaction between human tissues and lasers has been made possible. This has in turn helped the design and production of lasers for specifi c medical use (7).
In treating cutaneous tissue laxity and ageing, we can apply various techniques which are more or less invasive. There are three main methods; surgical lift-ing, radiofrequency technology lifting and infrared light lifting. Having used infrared radiation or radio-frequency treatments, we noticed a common advan-tage that does not apply to surgical lifting: the absence of scars, rapid recovery and the possibility of treating patients of any age or with a high anaesthetic risk (8). Both infrareds and radiofrequencies work on deep derma, overheating it in order to produce a contrac-tion of elastin and collagen fi bres and stimulating a collagen neosynthesis in the fi broblasts. Compared to radiofrequency, the infrared radiation determines a high initial contraction and a minor swelling of the treated tissues. Moreover, the use of infrared lights produced no effect on the subcutaneous tissue. On the other hand, the radiofrequency laser determined subcutaneous tissue atrophy (9).
Infrared radiation treatment is well tolerated by patients as it requires neither anaesthetic ointments nor anaesthetic sedation, both commonly used in radiofrequency treatment. Surgical lifting and the removal of excess skin are more effective than tech-niques. However, we must not treat patients with high anaesthetic risks, those undergoing pharmaco-logical therapy with anticoagulants and those not intending to undergo a surgical operation with an aesthetic aim.
Unlike the precedents a post-surgical period is nec-essary for full recovery. The presence of post-surgical scars (especially anti aesthetic on legs and arms) requires a close evaluation of the benefi ts and draw-backs of surgical intervention. We can also use some auxiliary techniques such as fi llers, botulinic toxin, photo-rejuvenation with lasers or pulsating lights that
Table II. Critical values of χ 2 corresponding to P � 0.05 and P � 0.01.
Probability of having χ 2 �
Degrees of freedom α � 0.05 o 5% α � 0.01 o 1%
1 3.841 6.6352 5.991 9.2103 7.815 11.3454 9.488 13.2775 11.070 15.0866 12.592 16.8127 14.067 18.4758 15.507 20.0909 16.919 21.666
10 18.307 23.209
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increase and integrate the infrared radiation treat-ment. Fillers like hyaluronic acid improve the mois-ture and volume of the tissues; botulinic toxin, with its paralysing action, determines wrinkle relaxation due to muscular hypertone; the photo-rejuvenation acts on the superfi cial layer of the epidermis (10).
The infrared light with a radiation energy range from 1100 to 1800 nm was used in this study (11). Its interaction with tissues makes the water tempera-ture in the deep dermis rise to about 20 ° C, causing contraction and retraction of the collagen and elas-tin. Another effect of raising the temperature is the stimulation of fi broblasts which, in the long run, determine a renewed production of collagen. The peculiarity of this treatment is to raise the tempera-ture in few seconds, rather than abruptly, so as not to determine a sensation of burning. Another pecu-liarity of infrared lights is the limited absorption at a deep dermis level, thus avoiding the involvement of the underlying tissues (12).
The treatment is well tolerated by patients who need neither local anaesthetic (lidocaine ointment) nor pharmacological sedation. The duration of the treatment is relatively brief (for example about 40 min for the face). It is necessary to cleanse the skin to remove cosmetics, lotion and oil; both patient and technician must wear the appropriate protective gog-gles. The treatment is carried out using an instru-ment with a rectangular contact surface of a variable dimension. The procedure is carried out through a series of single applications.
The single application is divided into three phases: a one second pre-cooling, followed by the irradiation of the infrared light and a fi nal post-application cooling.
In order to better vehiculate the cooling, a very thin layer of transparent gel for ultrasonography is used. This is the cooing vehicle that avoids possible burns as a perfect adhesion of the instruments ’ con-tact surface to the skin is fundamental. At the end of the treatment a rash or a swelling may appear on the treated areas. These effects are temporary and not at all serious.
Conclusion
The use of infrared radiation represents a valid alternative to surgical lifting, but it cannot replace it. The indication of these treatments should always be accurately evaluated, not only when referring to the local area where treatment is required, but also taking into consideration the patients ’ general condition. Elderly patients and patients with high surgical risk factors can be treated as this is a minor intervention, compared to surgical lifting which burdens the organ-ism with its duration and invasiveness. Moreover the handling of patients who have undergone similar treatments creates no diffi culty in it as far as support-ing therapies, excessive costs or psycho-physical stress. It is necessary to accurately select patients,
evaluating their tissue quality, to ensure that it con-tains a good quantity of moisture and collagen, which are usually associated with the presence of a good subcutis even if it will not be involved in the infrared application.
We must also consider the eventual contraindica-tions to the treatment (photosensitive medicines, presence of permanent prosthesis, pregnancy, herpes simplex in an active phase), and accurately illustrate the limits and benefi ts of this technique without intro-ducing the illusion of obtaining the same results of surgical lifting. Using the ancillary techniques, previ-ously explained, we may obtain excellent results.
Complications within the treated area as demon-strated by our case studies are nearly absent and led to a quick recovery with almost no residual scars.
In conclusion, the infrared radiation technique we used has turned out to be useful in contrasting skin laxity of the face and other parts of the body. Its effect has surely been amplifi ed by the supplemen-tary techniques we employed. The absence of scars and surgical risk makes this technique suitable for a vast range of patients. Nevertheless, we cannot defi ne it as an alternative to surgical lifting, which remains the most effective alternative.
Declaration of interest: The authors report no declarations of interest. The authors alone are respon-sible for the content and writing of the paper.
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