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to all patients that they should apply sun block (preferably containing titanium dioxide and zinc oxide) every day for 2 weeks before laser/lPl surgery, whether or not they engage in any outdoor activities. Ultraviolet light pro- tected clothing is also useful. The application of moder- ate-potency topical steroid immediately after laser and IPL surgery may also reduce the risk of PIH.
The use of topical bleaching agents before and after treatment may also be important. Many different combi- nation topical agents, containing tretinoin, hydroquinone, topical steroid, alpha-hydroxy acid (AHAJ, kojic acid, and/or azelaic acid, have been advocated In our practice, all patients are given a combination of azelaic acid mixed with 40lo hydroquinone and a moderate-potency steroid one day before treatment and then for 4 weeks after treat- ment. Tretinoin is added if the patient experiences no irritation If PIH develops despite the use of such agents, we add 50/o glycolic acid in the morning to further reduce the hyperpigmentation. Depending on the degree of irrita- tion, we add other bleaching agents, including vitamins C and E, and kojic acid. If PIH persists, then we perform a mild glycolic acid peel (20-35%J about 6 to 8 weeks after the treatment The use of microdermabrasion may also be effective as an adjunctive means to improve superficial
n i o m e n t a f i n n
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Chung JH, Lee SH, Youn CS, et al 2001 Cutaneous photodamage in Koreans: influence of sex, sun exposurer smoking, and skin color lu-chives of Dermatology I 37: I043-l 05 I
Elman M, Klein A, Slatkine M 2000 Dark skin tissue reaction in laser assisted hair removal with a long-pulse ruby laser. Journal o l C u t a n e o u 5 L a s e r lh e r a p l 2 : 1 7 - 2 0
Galadari I 2003 Comparative evaluation of different hair removal lasers in skin types IV, V, and VI International Journal of Dermatology 42:68-70
Goh CL, Chua SH, Ang P, Khoo L 2004 Efficacy of smoothbeam l,450nm laser for treatment of acne scars in Asian skin Lasers in Surgery and Medicine Sl6:76
Goldman MP 2000 The use of hvdroquinone with facial laser resurtacing Journal ol Cutaneous Laser Therapy 2:73-77 Greppi I 2001 Diode laser hair removal of the black patient Lasers
i n S u r g e r y a n d M e d i c i n e 2 8 : 1 5 0 - 1 5 5
Hardaway CA, Ross EV, Paithankar DY 2002 Non-ablative cutaneous remodeling with a I 45 microm mid-infrared diode laser: phase II Journal of Cosmetic Laser Therapy 4 : 9 - 1 4
Jeong JT, Kye YC 2001 Resurfacing of pitted facial acne scars with a long-pulsed Er:YAG laser Dermatologic Surgery 27:1,07-
I r 0
Kono T, Chan HH, Manstein D, Sesova IP, Nozaki M 2006 Comparison study of the down time and complications of fraxel laser skin rejuvenation, Lasers in Surgery and Medicine S 1 8 : 2 2 0
Kono T, Manstein D, Chan HH, Nozaki M, Anderson RR 2006 Q-switched Ruby vs Long-pulsed Dye Laser delivered with compression for treatment of facial lentigines in Asians, Lasers in Surgery and Medicine 38:94-97
Kono T, Nozaki M, Chan HH 2001 Diode laser assisted harr removal in Asians: a retrospective study of 101 Japanese patients. Lasers in Surgery and Medicine Sl3:245 Lee MW 2002 Combination visible and infrared lasers for skin
rejuvenation Seminars in Cutaneous Medicine and Surgery 2 t : 2 8 8 - 3 0 0
Lee JH, Huh CH, Yoon HJ, Cho KH, Chung JH 2006 Photoepila- tion results of axillary hair in dark-skinned patients by IPL: a comparison between different wavelength and pulse width Dermatologic Sur gery 32:73 4-24\
Nanni CA 1999 Laser assisted hair removal: side effects of Q- switched Nd:YAG, long-pulsed ruby, and alexandrite lasers Journal of the American Academy of Dermatology 4I :165-1 71 Negishi K, Tezuka Y, Kudshikata N, Wakamatsu S 2001 Photoreju-
venation for Asian skin by intense pulsed llght Dermatologic Swgery 27:677-632
Pandolfino T, Laubach H, Gagnon D, Manstein D 2006 CO2 laser induced ablative micropatterns in skin Lasers in Surgery and Medicine 37:5279
Rohrer TE, Chatrath V, Iyengar V Does pulse stacking improve the results of treatment with variable-pulse pulsed-dye lasers?
Dermatologic Surgery 2004; 30:163-167; discussion 167 Rokhsar CK and Fitzoatrick RE 2005 The treatment of melasma
with fractional photothermolysis: a pilot study Dermatologic S u r g e r y 3 l : 1 6 4 5 - 1 6 5 0
Ruiz-Esparza J, Gomez JB 2003 The medical face lift: a nontnva- sive, nonsurgical approach to tissue tightening in facial skin using nonablative radiofrequency Dermatologic Surgery 29:325-332;
discussion 332
Ruiz-Esparza J, Barba Gomez JM, Gomez de la Torre OL, Huerta Franco B, PargaYazquez EG 1998 UltraPulse laser skin resurfacing in Hispanic patients A prospective study of 36 individuals Dermatologic Surgery 24:59-62
Sadick NS, Makino Y 2004 Selective electro-thermolysis in aesthetic medicine: a review Lasers in Surgery and Medicine 3 4 : 9 1 - 9 7
Schroeter CA, Groenewegen JS, Reineke T, Neumann HA 2004 Hair reduction using intense pulsed light source Dermatologic Surgery 30: 1 68-1 73
Shek SY, Yu CS, Yeung CK, Kono T, Chan HH 2006 A study of non-thermal non-ablative LED photomodulation device for reversal of photoaging in Asians Lasers in Surgery and Medicine S 1 8 : 1 0 8
Shim EK, Barnette D, Hughes K, Greenway HT 2001 Microderm- abrasion: a clinical and histopathologic study Dermatologic S u r g e r y 2 7 : 5 2 4 - 5 3 0
Tanzi EL, Alster TS 2004 Long-pulsed 1064-nm Nd:YAG laser- assisted hair removal in all skin types Dermatologic Surgery 3 0 : I 3 - l 7
Tanzi EL, Williams CM, Alster TS 2003 Treatment of facial rhytides with a nonablative 1,450-nm diode laser: a controlled clinical and histologic study Dermatologic Surgery 29:724-128 Trelles MA 2001 Short and long-term follow-up of non-ablative
1320 nm Nd:YAG laser facial rejuvenation Dermatologic Svrgery 27:781-782
Trelles MA, Allones I, Luna R 2001 Facial rejuvenation with a non- ablative 1320 nm Nd:YAG laser: a preliminary clinical and histologic evaluation Dermatologic Surgery 27:1 I t-l l6 Tunnell JW, Chang DW, Johnston C, et al 2003 Effects of cryogen
spray cooling and high radiant exposures on selective vascular injury during laser irradiation of human skin Archives of Dermatology 139:7 43-7 50
West TB, Alster TS 1999 Effect of pretreatment on the incidence of hyperpigmentation following cutaneous C02 laser resurfacing Dermatologic Surgery 25:15-l 7
.r4trite
WM, Laubauch H, Makin IR, Slayton MH, Barthe PG, Gliklich R 2006 Selective trancutaneous delivery of energy to facial subdermal tissues using the ultrasound delivery system Lasers in Surgery and Medicine 37:Sl 13
Laser Treatment of Cetlutite
Adam M. Rotunda, Jaggi Rao, Mitchel P. Gotrdman
INTRODUCTION
Just as apparently inevitable r,r.rinkling is with aging, so apparently inevitable is ceilulite on a woman's thigh or buttock. The characteristic cutaneous irregularity and dimpling on the buttocks, and upper outer or posterior thighs on more than 850/o of post-pubertal women could quahfy cellulite as a secondary female sex characteristic The condition leaves many women feeling unattractive It would appear that a topical, surgical, light-based, or mechanical treatment that cures cellulite would be to women what penicillin was to the world of infectious disease-akin to a miraclel Although this chapter does not describe miracles, it aims to elaborate on studies that have investigated cellulite and describe the increasingly popular treatments that may improve the appearance of this medically benign, but cosmetically disturbing condition.
. Definition
'Celluiite'
was described over 150 years ago in France, and has since been referred to as adiposis edematosa, dermopannniculosis deformans, status protrusus cutis, and gynoid lipodystrophy, and 'orange
peel' or 'cottage cheese' dimpling. It has been proposed that clinicians substitute the single term cellulite with incipient cellulite and t'ull-blown cellulite Incipient cellulite is identified by the mattress phenomenon, a gender-specific feature of the skin that is demonstrated by the pinch test, apparent even in a female infant (Fig. 6.r) Pinching the skin tethers the dermis to a deeper layer of connective tissue and forces clusters of adipose tissue into the overlying skin. Full- blown cellulite is characterized by permanent (as opposed to induced), gross cutaneous irregularity. A cellulite clini- cal grading system that accounts for this clinical spectrum has been described fsee Table 6 1)
Despite its prevalence and unsightly presence, there has only been a modest amount of scientific investigation into cellulite Scant research leads to innumerable pur- ported treatments, misconceptions, and controversy There are no unrversally accepted causes, no gold-standard treatments, nor preventive strategies for the condition.
Thankfully, there is no apparent morbidity or mortality associated with the condition. With an appreciation of
what is already known and speculated, we may be better equipped to appraise the newer technologies and tech- niques that have arisen to treat it. For a complete discus- sion of the pathophysiology and treatment of cellulite, the interested reader is referred to a complete textbook on this subject.
o Predisposing factors
There are many factors that contribute to a patient's pre- disposition for cellulite:
'i, Gender: due to underlying structure of fat and connective tissue described above, women are more likely to develop cellulite
"i, Heredity: empirically, it has been found that the degree and presence of cellulite, as with body habitus, is often similar between females within the same famiiy
* Race: Caucasian women are more iikely to develop cellulite than Asian or African-American women t, Increased subcutaneous fat: due to the unique
histology of skin with cel1u1ite, it is evident that greater adipose tissue in the subcutaneous layer enhances the appearance of cellulite on the skin surface
,i' Age: women begin to develop cellulite after puberty as part of normal anatomic and physiological develop- ment, combined with hormonal influences
Unfortunately, these predisposing factors are difficult if not impossible to alter. However, based on our under- standing of the etiology and nature of this condition, several treatment modalities have been developed
Hormones, specifically estrogens, are thought to influ- ence the formation of cellulite. Estrogen is known to stimulate lipogenesis and inhibit lipolysis, resulting in adi- pocyte hypertrophy (Rossi and Vergnanini, 2000). This may explain the onset of full-blown cellulite at puberty, the condition being more prevalent in females, and the exacerbation of cellulite with pregnancy, nursing, men- struation, and estrogen therapy (oral contraceptive use and hormone replacement). The opposite seems true for men. From the limited number of studies involving men,
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L a s e r s a n d L i g h t s V o l u m e l l
Fig. 6.1 Upper-thigh skin before (A) and after (B) the pinch test, which demonstrates the'mattress phenomenon.' The changes observed, apparent here in a s-month-old female infant, strongly suggest structural rather than acquired or environmental factors contribute to cellulite
it is hypothesized that the combination of gender-specific soft-tissue histology at the cellulite-prone anatomic sites, with a relatively lower circulating estrogen level, may be responsible for the lower incidence of cellulite in males.
Adipose tissue is relatively vascular, ieading to the theory that cellulite may appear and worsen in predis-
5
Fig. 6.2 A schematic diagram of skin structure showing five zones The gray layer is the epidermis Zone 1 is the dermis Zone 2 is the extrusion of the hypodermis into the dermis Zones 3-5 are the upper, middle, and lower parts of the hypodermis, (Reprinted by permission of Blackwell {rom Mirrashed F, Sharp JC, Krause V, Morgan., Tomanek B Pilot study of dermal and subculaneous fat structures by MRI in individuals who differ in gender, BMl, and cellulite grading Skin Res Technol 2004;10:161-8)
posed areas when circulation and lymphatic drainage have been compromised. In response to impairment of micro- vascular circulation, it is proposed that microedema within the subcutaneous fat layer causes further pressure on sur- rounding connective tissue fibers and accentuation of skin irregularities. A number of the more novel cellulite thera- pies attempt to augment lymphatic drainage and mrcro- vascular circulation.