Clinical Procedures in Laser Skin Rejuvenation - part 3 pps

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 10ms. 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 38 Clinical procedures in laser skin rejuvenation 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 Ablation speed Pulse duration (ms) 0 0.5 1.0 1.5 Thermal effect 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. 04 Carniol-8028.qxd 8/23/2007 3:34 PM Page 38 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 CO 2 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 CO 2 laser resurfacing for the treat- ment of perioral rhytides. 9 Although a reduced duration of re-epithelialization was noted with the modulated Er:YAG laser (3.4 days vs 7.7 days with a CO 2 laser), the clinical results observed were less impressive than those following CO 2 laser resurfacing. Er:YAG laser sys- tems may greatly improve atrophic scars caused by acne, Erbium laser aesthetic skin rejuvenation 39 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 04 Carniol-8028.qxd 8/23/2007 3:34 PM Page 39 40 Clinical procedures in laser skin rejuvenation 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 04 Carniol-8028.qxd 8/23/2007 3:34 PM Page 40 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 laser 10 . 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 20µm 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 40–60µm 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 60–80µm, 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 CO 2 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 CO 2 laser pass after completing the medium-depth LASR. This involves spatially separated pulses of the CO 2 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 Erbium laser aesthetic skin rejuvenation 41 04 Carniol-8028.qxd 8/23/2007 3:34 PM Page 41 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 400mg three times daily, or valacyclovir 500mg 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 42 Clinical procedures in laser skin rejuvenation Fig.4.11 Combination resurfacing techniques utilize other modalities to achieve the same endpoint that multiplexing pulse duration achieves. Ablative bipolar radiofrequency or fractional CO 2 laser treatment to the upper dermis enhances hemostasis and collagen contraction. 04 Carniol-8028.qxd 8/23/2007 3:34 PM Page 42 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 CO 2 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 (500mW for continuous-wave and 10J/cm 2 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 CO 2 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 Erbium laser aesthetic skin rejuvenation 43 04 Carniol-8028.qxd 8/23/2007 3:34 PM Page 43 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 CO 2 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 CO 2 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 CO 2 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). 44 Clinical procedures in laser skin rejuvenation 04 Carniol-8028.qxd 8/23/2007 3:34 PM Page 44 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 (CO 2 ) 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 CO 2 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 05 Carniol-8028.qxd 8/23/2007 10:26 AM Page 45 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 46 Clinical procedures in laser skin rejuvenation Fig.5.1 Severe herpes simplex infection post carbon dioxide laser resurfacing (by permission of Jean Rosenbloom) 05 Carniol-8028.qxd 8/23/2007 10:26 AM Page 46 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 CO 2 laser burn Fig.5.3 Hypertrophic scarring after long-pulse YAG laser treatment of a tattoo. 05 Carniol-8028.qxd 8/23/2007 10:26 AM Page 47 [...]... deeply in the dermis to improve wrinkles.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 06 Carniol-8028.qxd 60 8/ 23/ 2007 3: 32 PM Page 60 Clinical procedures in laser skin rejuvenation Table 6.4 Results of photodynamic therapy with δ-aminolevulinic... Carniol-8028.qxd 48 8/ 23/ 2007 10:26 AM Page 48 Clinical procedures in laser skin rejuvenation a b Fig 5.4 Scarring and pigmentation from improper use of an IPL Device 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... 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 06 Carniol-8028.qxd 54 8/ 23/ 2007 3: 32 PM Page 54 Clinical procedures in laser skin rejuvenation a b c d Fig 6 .3 (a,b) A 27-yearold man whose acne scars had been treated three... treatment 0a 06 Carniol-8028.qxd 58 8/ 23/ 2007 3: 32 PM Page 58 Clinical procedures in laser skin rejuvenation a b 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... (KTP) laser device is readily absorbed by oxyhemoglobin and melanin ,34 making it especially 06 Carniol-8028.qxd 56 8/ 23/ 2007 3: 32 PM Page 56 Clinical procedures in laser skin rejuvenation a 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 ... 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... months, 3/ 10 with moderate to severe wrinkling showed clinical improvement at 3 months Transient purpura, swelling Up to 14 585/2.4/ 0 .35 0 Statistically significant decreases in Fitzpatrick class I, II, III wrinkles None Up to 6 Facial dyspigmentation and wrinkling (4) 585 or 595/ 3 4/0.5 Clinically observable improvement in dyspigmentation and wrinkling for all subjects None 6 Periorbital wrinkling (1... 0 .35 Improvements in surface topography of 9.8% (one treatment) and 15% (two treatments) Minor pain 1, 3 during initial treatment, minimal temporary reddening a Efficacy b 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 downtime and the risk of long-term hypopigmentation and scarring Microablative Fractional photothermolysis (FP) has recently been introduced for ‘microablative’ resurfacing.20,21 06 Carniol-8028.qxd 52 8/ 23/ 2007 3: 32 PM Page 52 Clinical procedures in laser skin rejuvenation a b c 100 µm 100 µm 0 days d 100 µm 1 days 3 days 100 µm 7 days Fig 6.1 Photomicrograph of skin treated with fractional device,... were more common with IPL In a 9 3- 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 06 Carniol-8028.qxd 8/ 23/ 2007 3: 32 PM Page 55 Nonablative . edges are ‘feathered’(c).The final result is shown in (d). b c d a 04 Carniol-8028.qxd 8/ 23/ 2007 3: 34 PM Page 39 40 Clinical procedures in laser skin rejuvenation Fig.4.10 This treatment took place. these Erbium laser aesthetic skin rejuvenation 43 04 Carniol-8028.qxd 8/ 23/ 2007 3: 34 PM Page 43 procedures in any patient predisposed to delayed or abnormal cutaneous wound healing will reduce the fre- quency. or training in dermatology could reasonably fulfill all of the 46 Clinical procedures in laser skin rejuvenation Fig.5.1 Severe herpes simplex infection post carbon dioxide laser resurfacing (by