o Other sites
Off-the-face treatment sites have become increasingly popular targets for monopolar RF treatment and studies, and include the lower abdomen for skin laxity (age related, post-pregnancy, or post-liposuction; Fig. 4.9), tissue areas adjacent to the breasts for tightening and lifting, arms, and others Currently there are no validated treatment algo- rithms for these off-the-face sites, but typically multiple passes (600-900 pulsesJ are used at moderate treatment settings (352 0-354.5J. Skin tightening and celluiite improvement are two FDA approved indications off the face with ThermaCool TC.
Alexiades-Armenakas and Goldberg have completed FDA trials employing the Accent for the treatment of skin laxity and cellulite on the body. It has been granted approval for body rhytides to date (Fig.4.t4)
Fig' 4'12 Nodules secondary to treatment with Thermage Temporary nodules (A) and cheek swelling (B) '1 week following treatment
Fig. 4.13 Tightening of abdominal skin with ThermaCool TC Patient prior to (A) and 1 year following (B) one pass at 15.5
Fig.4.14 Cellulite treatment with Accent Right leg following five treatments with left leg as untreated control. (Photographs courtesy of Dr. Alexiades-Armenakas)
The VelaSmooth [Syneron] system has been approved for the treatment of cellulite. As aforementioned, it com- bines RF with broad-spectrum infrared light and suction.
It is currently undergoing FDA trials for the treatment of striae distensae.
Skin Tightening with Radiofrequency
DTSCUSStON
Radiofrequency devices for tissue tightening are the latest and perhaps most distinctive treatment option in the quest for nonablative rejuvenation. Studies show that these devices can lead to substantial improvement in skin laxity and rhytides, with newer devices and treatment algorithms providing greater consistency in results. Because the treatment risks are extremely low, this is a relatively simple alternative for patients who do not want major surgery or who have moderate skin laxity that does not warrant an invasive surgical procedure.
One of the central questions is what the role of RF will be in the future of facial rejuvenation. It is clear that RF tissue tightening produces effects that are not achievable with other devrces currently on the market. And although a facelift may be an option for some, many patients are reluctant to go through the expense and recovery of such a procedure. For these and other reasons, the RF skin tightening procedure is likely to become a central part of facial rejuvenation.
In exploring the mechanisms and effects of photoaging, there are two basic components: (il superficial (epider- mal) and (ii) deeper (dermal, subcutaneous) structural changes (sagging). Although the RF procedure may yet be determined to have some benefit on superficial epidermal changes, that would be a secondary effect. But it is clear that the technique has a direct and at times profound effect on dermal and subdermal tissues. This is where the uniqueness of the RF becomes its greatest utility
Other devices exist for treatment of epidermal changes Iablative resurfacing, chemical peels, pigment lasers, photorejuvenation), and dermal remodeling can be achieved with several of the non-ablative lasers. Yet none of these techniques or devices is capable of producing nonablative tissue tightening, and that is clearly the niche for radiofrequency to fill. Since sagging of tissues ts a fundamental part of the aging process, nearly all patients who are candidates for other forms of facial rejuvenation are also candidates for the radiofrequency procedures.
Radiofrequency tissue tightening is not a substitute for the wide array of nonablative lasers, but rather a companion to them. There may be some overlap, for example, in remodeling of the dermis achieved by nonablative lasers and the radiofrequency wavelengths. However, only RF can produce tightening of dermal collagen in the x and y axes, and the z-axis changes discussed earlier are not seen with any of the other nonablative options available.
Recently, a new infrared device emitting wavelengths from I 100 to 1800 nm has been introduced for the treat- ment of skin laxity (Titan, Cutera). This technology is postulated to function by causing broad-based heating of the dermis, which is followed by tissue contraction. To date, early data, which has not been peer-reviewed, suggest its safety and moderate degree of efficacy in treat- ing rhytides and laxity. In one preliminary study of 25 patients, fluences of 20-30 J/cm2 produced immediate changes and moderate improvement in rhytides of facial
7 2
Lasers and Lights Volume ll
skin In a preliminary split-face design study comparing this modality to RF, discussed below, a more mild improve- ment was reported using the infrared device It will be interesting to monitor the efficacy of this device as the final reports become available. Further studies will be needed to better determine the effectiveness of this device compared with RF in the skin tightening arena.
Radiofrequency devices are continually being advanced for the treatment of rhytides, laxity, and cellulite. Physi- cians now have a nonsurgical alternative to the facelift utilizing these technologies, provided that proper patient selection and management of expectations are achieved.
It is most useful for those oatients who would benefit from dermal remodeling, as well as from tissue tightening of the forehead, cheeks, jawhne, and neck. \A/hen RF techniques are combined with other procedures that improve the more superficial changes associated with photoaging, patients are likeiy to experience results that were previously impossible to achieve in the absence of more aggresslve, lnvaslve surgery.
FURTHER READING
Alexiades-Armenakas MR 2006 Rhytides, laxity and photoaging treated with a combination of radiofrequency, diode laser, and pulsed light and assessed with a comprehensive grading scale Journal of Drugs Dermatology 5:609-616
Doshi SN, Alster TS 2005 Combination radiofrequency and diode laser for treatment of facial rhytides and skin laxity Journal of Cosmetic Laser Therapy 7:l 1-15
Dover JS, Zelickson B, Atkin D, et al 2005 A multi-specialty review and ratification of standardized treatment gurdelines for optimizing tissue tightening and contouring with a non-invasrve monopolar radiofrequency device American Society of Dermatologic Surgery Abstracts Atlanta, GA, October 28 Fitzpatrick R, Geronemus R, Goldberg D, Kaminer M, Kilmer S,
Ruiz-Esparza J 2003 Multicenter study of noninvasive radiofrequency for periorbital tissue tightening Lasers in Surgery and Medicine 33:237-242
Hsu TS, Kaminer MS 2003 The use of non-ablative radiofrequency technology to tighten the lower face and neck Seminars in Cutaneous Medicrne and Surgery 22:II5-l'23
Jacobson LG, Alexiades-Armenakas MR, Bernstein L, Geronemus RG 2003 Treatment of nasolabial folds and jowls with a non- invasive radiofrequency device Archives of Dermatology I 3 9 : 1 3 I 3 - l 3 2 0
Lee M-W C 2005 Comparison of radiofrequency vs 1100-1800 nm infrared light for skin laxity American Society of Dermatologic Surgery Abstracts, Atlanta, GA, October 28
Ruiz-Esparza J 2005 New infrared device can produce immediate and long-term skin contraction by painless low fluence irradiation American Society of Dermatologic Surgery Abstracts, Atlanta, GA, October 28
Ruiz-Esparza J, Gomez JB 2003 Nonablative radiofrequency for active acne vulgaris: The use of deep dermal heat in the treatment of moderate to severe active acne vulgaris (Thermo- therapy): A report of 22 patients Dermatologic Surgery 2 9 : 3 3 3 3 3 9
Sadick N, Alexiades-Armenakas M, Bitter P, Hntza G, Mulholland S 2005 Enhanced full-face skin rejuvenation using synchronous intense pulsed optical and conducted, bipolar radiofrequency energy (ELOS) : introducing selective radiophotothermolysis Journal of Drugs Dermatology 4:l8l-186
Zelickson BD, Kist D, Bernstein E, et al 2004 Histological and ultrastructural evaluation of the effects of a radio-frequency- based non-ablative dermal remodeling device: A pilot study.
Archives of Dermatoloev 1 40.204-709
Laser Treatment of Ethnic Skin
Henry H.L. Chan, Taro Kono
I N T R O D U C T I O N
Dark-skinned patients have significantly higher epidermal melanin content than their lighter-skinned counterparts.
This melanin can act as a competing chromophobe Thus, the use of lasers for the treatment of vascular lesions, such as facial telangiectasia, or hair removal in darker skinned individuals is more likely to give rise to adverse effects.
These adverse events lnclude blistering, crusting, dyspig- mentation, and even scarring In addition, because epider- ma1 melanin acts as a competing chromophore, the light dosage that reaches the targeted blood vessels is reduced, and higher fluences may be necessary to produce a suffi- cient effect Indeed, clinicians u'ho are less familiar r'vith the treatment of dark-skinned patients are often con- cerned about their perception of lessened clinical outcome and the increased risk of adverse effects
Darker skinned individuals have an increased risk of laser-induced complications. However they, like lighter skinned individuals, also may present signs of photoaging rvith pigmentary conditions such as lentigines and sebor- rheic keratosis, and even mild wrinkling Chung et al (2001J looked at 407 Koreans between the ages of 30 and 92 years and assessed the cutaneous manifestation of photoaging. Their findings revealed that pigmentary changes are common features of photoaging in patients r,vith skin types III and IV. Seborrheic keratosis is the main pigmentary lesion in men, whereas lentigines are common among women.
Conditions such as Hori's macules, while uncommon in Caucasians, are frequently encountered in dark-skinned patients, especially Asians This chapter addresses the cos- metic use of laser and intense pulsed light source on dark- skinned patients, with the aim of obtaining optimal results nhile reducing the risk of complications. The logic behind our approach as well as the management of postinflamma- tory hyperpigmentation (PIH) are also discussed.
. The problem being treated
This chapter will also review particular aspects of non- ablative skin rejuvenation, ablative skin rejuvenation, the treatment of telangiectasia, and hair removal, with refer- ence to their effects on dark-skinned oatients.
Acquired bilateral nevus of Ota-like macules IABNOM), or Hori's macules, affects about 0.8% of the population in Asia. C1inica1ly, it presents as a bluish hyperpigmenta- tion that usually affects the bilateral malar regions Other areas can also be involved, including the temples, the root of the nose, the alae nasi, the eyelids, and the forehead In contrast to nevus of Ota, in ABNOM the pigmentation occurs in a symmetrical bilateral fashion, has a late onset in adulthood, and does not involve the mucosa Laser treatments can now be used to improve this pigmentary alteration, r'vhich tends to be more resistant to treatment than nevus of Ota. RoshanKetab 02I-66950639
In terms of photoaging, as described above, dark- skinned Datients tend to have fewer wrinkles than Caucasians. Laser resurfacing is not as commonly used in darker skin types Conversely, the possible adverse effects of laser resurfacing, such as erythema and PIH, are more common u'ith dark-skinned patients Nonetheless, laser resurfacing is sti11 performed, mainly in patients with acne scarring. Fractional resurfacing has gained much popular- ity in Asia due to its potentially lower risk of complica- tions and downtime It is particularly effective for acne scarring and rejuvenation for those with more significant degrees of photoaging.
The most common complication in dark-skinned patients, after laser surgery, is PIH. Although this is tran- sient, it can last for several months and is poorly tolerated by most patients. Recent advances in skin cooling and longer laser rvavelengths and pulse durations, have improved treatment outcomes in laser hair removal and the treatment of telangiectasia in dark-skinned patients.
PATIENT SELECTION
Due to the higher risk of postoperative complications, especially PIH, and less wrinkling in dark-skinned patients, nonablative skin rejuvenation procedures, using lasers, intense pulsed light sources (lPL), and radiofrequency (RF) devices are presently the first line of treatment for dark-skinned patients r,r'ho request treatment for photoaging.
Although nonablative skin rejuvenation has been used for acne scarring, the degree of improvement ranges from m i l d t o m o d e r a l e a t b e s t A s a r e s u l t , l a s e r r e s u r f a c i n g o r
L a s e r s a n d L i g h t s V o l u m e ll
fractional resurfacing, in combination with other surgical procedures such as subcision and punch biopsy, remains the therapeutic option that offers the optimal clinical outcome.
Dark-skinned patients also seek laser- and light-based hair removal. Such individuals often present with fine black hair and tend to have a poorer response than lighter skinned individuals who have thicker hairs. Nevertheless, laser hair removal often delivers particularly good results, coupled with a low risk of complication in the removal of hair from areas that are not normally exposed to the sun, such as the armpit.
Finally, darker skinned individuals may present with telangiectasias. Facial telangiectasia can be effectively re- moved with IPL and/or a long pulse width laser equipped with cooling. For larger vessel leg telangiectasia (>2 mm), sclerotherapy remains the treatment of choice.
r Exclusion criteria
Patients with acne scarring who have been treated with isotretinoin within the last 6 months should be excluded from laser resurfacing. For laser hair removal, recent hair bleaching and plucking are best avoided a short period of time before laser/light based treatment.
Recent suntan predisposes dark-skinned patients to a higher risk of PIH after all laser and IPL treatments.
Hence, sun protection and avoidance is necessary for at least 2 weeks before any such treatment. The use of topical bleaching agents 2 weeks before the treatment may also be helpful. Photosensitizing drugs, such as tetra- cycline, can also increase the risk of PIH, and are best avoided for 2 weeks before and after any laser/IPl procedure.
EXPECTED BENEFITS
In combination with subcision and punch biopsy, laser resurfacing or fractional resurfacing for acne scarring can lead to significant improvement (>700/o) in some individu- als (Fig. 5.:.). For patients with photoaging, that have not responded to a nonablative procedure, fractional resurfac- ing or laser resurfacing can also lead to substantial improve- ment. Fractional resurfacing has been shown to be effective for the treatment of melasma, but in one of the authors' (HC) experience only some melasma patients respond well to it (approximately 50-600/o experience some degree of clearing; Fig. S.z). This is in line with a previous publi- cation that suggested 60% of patients experience signifi- cant improvement, 30o/o experience a mild degree of lightening, and 10% ofpatients experience a worsening of their melasma. Postinflammatory hyperpigmentation can occur with fractional resurfacing, but the risk is signifi- cantly less compared with that seen with laser resurfacing.
By reducing the energy and density of laser treatments, the risk of PIH following the treatment for acne scarring and wrinkle reduction can be reduced to less than 30/0.
Fractional resurfacing can now be performed with
Fig. 5.1 Acne scarring improved after fractional resurfacing (20 mJ, 500 MTZ, 8 treatment sessions) (parallel polarized view)
multiple different devices. The initially described method involves the use of a scanning device that delivers a laser injury when the device moves across the skin surface fscanning mode). Other devices involve the placement of the laser handpiece on the skin's surface in a stamping fashion (stamping mode). Some stamping devices are associated with multiplatform devices that can also deliver IPL and/or other laser treatments. Newer frac- tional resurfacing scanning technology also allows for alteration in spot size with different fluences. By rncreas- ing the spot size with higher fluence, the depth of penetra-
7 5
Fig. 5.2 Epidermal melasma improved after fractional resurfacing (6-14 mJ 1000-1500 MTZ, 6 treatment sessions) (cross polarized view)
tion increases, which reduces the risk of bulk tissue heating-an issue of particular concern in ethnic skin Reduction in bulk heating will reduce PIH in dark-skinned patients. Bulk heating induced PIH is also lessened with the use of appropriate cooling. Air cooling is currently used with fractional resurfacing with the scanning mode device; contact cooling is incorporated into some of the stamping mode devices.
Photoaging in dark-skinned patients often presents with an increase in pigmentation. The use of lasers and IPL sources can lead to a 90-1000/o degree of improvement in epidermal pigmentation. Although fewer treatment sessions are necessary when a laser is used (l-2 sessrons, compared with 5-6 when IPL is used), PIH is a greater risk in the laser-treated group and can occur in l0-150/o of laser-treated patients, depending upon factors such as the type of device used, the skill of the operator, and patient factors such as recent sun exposure (Fig. f.:). IPL has the advantage of no downtime, improvement in other parameters of aging, and a lower risk of PIH.
ABNOM can be treated with QS lasers (ruby, alexan- drite and 1064-nm neodymium : yttrium-aluminum-garnet
Laser Treatment of Ethnic Skin
[Nd:YAG]). Four to eight treatment sessions at intervals of 4-6 weeks are necessary to achieve a significant to complete degree of clearing. PIH occurs in 72-730k of treated patients, and topical bleaching agents should be used. Hypopigmentation can occur in up to 50% of patients, and the possibility of such a complication should be discussed with each patient in advance (Fig.S'+).
Vascular lasers, when used to treat telangiectasia and in the area of nonablative skin rejuvenation, induce vessel injury with the aim of creating healing and subsequent collagen production. Facial telangiectasia can be effec- tively treated with a variety of long pulsed dye, variable pulse 532 nm Nd:YAG, long pulsed alexandrite, and long pulsed 1064-nm Nd:YAG lasers, all equipped with different types of cooling devices. Complete, or near complete, resolution with minimal adverse effect can be expected aker 2-4 treatment sessions. Leg telangiectasia, with larger vessel diameters, are more resistant, and generally require more sessions. In some cases, leg telan- giectasia are treated with a combination of modalities including sclerotherapy.
In terms of using cooling for vascular lesion laser treat- ments/ cryogen cooling with the pulsed dye laser was examined in the treatment of port-wine stains in skin types III and IV, and was found to be highly effective.
However, for skin types V and VI, epidermal protection could not be achieved even at the lowest radiant laser exposure (8 J/cm'z). A variable pulsed 532 nm Nd:YAG laser, equipped with contact cooling with a water glass chamber, was also comparatively ineffective when used in the treatment of port-wine stains in skin types III and IV, but could be used effectively for the treatment of facial telangiectasia. There is only limited data on the optimal cooling parameters and efficacy of other cooling devices for the treatment of vascular lesions when used in dark- skinned patients.
As described above, vascular lasers have also been used to induce vessel injury, with the subsequent healing process producing collagen. Although considerable data has been collected on the use of vascular lasers on Cauca- sians, data on dark-skinned patients is limited. Further- more, studies looking at the use of these devices for the treatment of port-wine stains in dark-skinned patients have shown a higher risk of complication. Issues such as the optimal fluence, clinical efficacy, and possible adverse effects when such lasers are used for nonablative skin rejuvenation for dark-skinned patients have not yet been investigated.
Lasers with wavelengths in the near infrared spectrum have also been used for wrinkle improvement. With such devices, the goal is to heat the dermis, thereby increasing the amount of collagen by eliciting an increase in fibro- blastic activity. Although many devices are now used for such purposes, data on their effects on dark-skinned patients remains limited. A millisecond-domain 1064-nm Nd:YAG laser, used in conjunction with a long-pulsed 532-nm potassium titanyl phosphate (KTP) laser, has been successfully used for nonablative skin rejuvenation