Clinical Procedures in Laser Skin Rejuvenation - part 5 pptx

86 Clinical procedures in laser skin rejuvenation 20. Lee WL, Shalita AR, Poh-Fitzpatrick MB. Comparative studies of porphyin production in Propionibacterium acnes and Propionibacterium granulosum. J Bacteriol 1978;133: 811–15. 21. Ashkenazi H, Malik Z, Harth Y et al. Eradication of Propionibacterium acnes by its endogenic porphyrins after illumination with high intensity blue light. FEMS Immunol Med Microbiol 2003;35:17–24. 22. Kjeldstad B, Johnsson A.An action spectrum for blue and near ultraviolet inactivation of Propionibacterium acnes; with emphasis on a possible porphyrin photosensitization. Photochem Photobiol 1986;43:67–70. 23. Kjeldstad B. Photoinactivation of Propionibacterium acnes by near-ultraviolet light. Z Naturforsch [C] 1984; 39:300–302. 24. Melo TB. Uptake of protoporphyrin and violet light pho- todestruction of Propionibacterium acnes. Z Naturforsch [C] 1987;42:123–8. 25. Elman M, Lebzelter J. Light therapy in the treatment of acne vulgaris. Dermatol Surg 2004;30:139–46. 26. Charakida A, Seaton ED, Charakida M et al. Phototherapy in the treatment of acne vulgaris:What is its role? Am J Clin Dermatol 2004;5:211–16. 27. Mills OH, Porte M, Kligman AM. Enhancement of comedogenic substances by UV radiation. Br J Dermatol 1978;98:145–50. 28. van Weelden H, de Gruihl FR, van der Putte SC et al.The carcinogenic risks of modern tanning equipment: is UV-A safer than UV-B? Arch Dermatol Res 1988;280:300–307. 29. Kawada A,Aragane Y, Kameyama H et al.Acne photother- apy with a high-intensity, enhanced, narrow-band, blue light source: an open study and in vitro investigation. J Dermatol Sci 2002;30:129–135. 30. Omi T, Bjerring P, Sato S et al. 420 nm intense continuous light therapy for acne.J Cosmet Laser Ther 2004;6:156–162. 31. Shalita AR, Harth Y, Elman M et al.Acne phototherapy using U.V free high intensity narrow band blue light: 3 centres clinical study. Proc SPIE 2001;4244:61–73. 32. Elman M, Slatkine M, Harth Y.The effective treatment of acne vulgaris by a high-intensity, narrow band 405–420 nm light source. J Cosmetic & Laser Ther 2003;5:111–117. 33. Tzung TY,Wu KH, Huang ML. Blue light phototherapy in the treatment of acne. Photodermatol Photoimmunol Photomed 2004;20:266–69. 34. Gold MH, Rao J, Goldman MP et al.A multicenter clini- cal evaluation of the treatment of mild to moderate inflammatory acne vulgaris of the face with visible blue light in comparison to topical 1% clindamycin antibiotic solution. J Drugs Dermatol 2005;4:64–70. 35. Sigurdsson V, Knults AC, van Weelden H. Phototherapy of acne vulgaris with visible light. Dermatology 1997;194: 256–60. 36. Young S, Bolton P, Dyson M et al. Macrophage responsive- ness to light therapy. Lasers Surg Med 1989;9:497–505. 37. Papageorgiou P, Katsambas A, Chu A. Phototherapy with blue (415nm) and red (660nm) light in the treatment of acne vulgaris. Br J Dermatol 2000;142:973–8. 38. Edwards C, Hill S,Anstey A.A safe and effective yellow light-emitting diode treatment for mild to moderate acne: A within-patient half-face dose ranging study. Abstract. J Am Acad Dermatol.AB15; March 2006. 39. Gupta A. Efficacy and safety of intense pulsed light ther- apy using wavelengths of 400–700nm and 870–1200nm for acne vulgaris. J Am Acad Dermatol AB27, March 2006. 40. Elman M, Lebzelter J. Evaluating pulsed light and heat energy in acne clearance. Radiancy White paper, June 2002. Retrieved from http://www.radiancy.com/USA/ appdocs.htm. 41. Herd RM, Dover JS, Arndt KA. Basic laser principles. Dermatol Clinic 1997;15:355–72. 42. International Union of Pure and Applied Chemistry Compendium of Chemical Terminology 2nd edition, 1997. Retrieved from http://www.iupac.org/gold- book/A00446.pdf. 43. Elman M, Lask G.The role of pulsed light and heat energy (LHE) in acne clearance. J Cosmet Laser Ther 2004;6: 91–95. 44. Gregory AN,Thornfeldt CR, Leibowitz KR et al.A study on the use of a novel light and heat energy system to treat acne vulgaris. Cosmet Dermatol 2004;17:287–300. 45. Baugh,WP and Kucaba WD. Nonablative phototherapy for acne vulgaris using the KTP 532 nm Laser. Dermatol Surg 2005;31:1290–6. 46. Bowes LE, Manstein D, Anderson RR. Effects of 532nm KTP laser exposure on acne and sebaceous glands. Lasers Surg Med 2003;18:S6–S7. 47. Lee CMW.Aura 532nm laser for acne vulgaris – a 3 year experience, Annual Combined Meeting of the American Society for Dermatologic Surgery and the American Society for Mohs Micrographic Surgery and Cutaneous Oncology, New Orleans, LA, October 2003. 48. Seaton ED, Charakida A, Mouser PE et al. Pulsed-dye laser treatment for inflammatory acne vulgaris: ran- domised controlled trial. Lancet 2003;362:1347–52. 49. Orringer J, Kang S, Hamilton T et al.Treatment of acne vulgaris with a pulsed dye laser: a randomized controlled trial.JAMA 2004;291:2834–9. 50. Chu A.Pulsed dye laser treatment of acne vulgaris.JAMA 2004;292:1430. 51. Alam M, Peterson SR, Silapunt S et al. Comparison of the 1450nm diode laser for the treatment of facial acne: a left-right randomized trial of the efficacy and adverse effects. Lasers Surg Med 2003;32:S30. 07 Carniol-8028.qxd 8/23/2007 10:28 AM Page 86 52. Ortiz A,Van Vilet M, Lask GP,Yamauchi PS. A review of laser and light sources in the treatment of acne vulgaris. J Cosmetic and Laser Therapy 2005;7:69–75. 53. Ashkenazi H, Malik Z, Harth Y et al. Eradication of Propionibacterium acnes by its endogenic porphyrins after illumination with high-intensity blue light. FEMS Immunol Med Microbiol 2003;35:17–24. 54. Gold MH, Bradshaw VL, Boring MM et al.The use of a novel intense pulsed light and heat source and ALA-PDT in the treatment of moderate to severe inflammatory acne vulgaris. J Drugs Dermatol 3(6 Suppl):S15–9, 2004 Nov-Dec. 55. Hongcharu W,Taylor CR, Change Y et al.Topical ALA- photodynamic therapy for the treatment of acne vulgaris. J Invest Dermatol 2000;115:183–92. 56. Itoh Y, Ninomiya Y,Tajima S et al. Photodynamic therapy for acne vulgaris with topical 5-aminolevulinic acid.Arch Dermatol 2000;136:1093–1095. 57. Itoh Y, Ninomiya Y,Tajima S et al. Photodynamic therapy for acne vulgaris with topical delta-amenolevulinic acid and incoherent light in Japanese patients. Br J Dermatol 2001;144:575–579. 58. Goldman MP. Using 5-aminolevulinic acid to treat acne and sebaceous hyperplasia. Cosmet Dermatol 2003;16: 57–58. 59. Gold MH, Bradshaw VL, Boring MM et al.The use of a novel intense pulsed light and heat source and ALA-PDT in the treatment of moderate to severe inflammatory acne vulgaris. J Drugs Dermatol 2004;3:S15–S19. 60. Pollock B,Turner D, Stringer MR et al.Topical amenole- vulinic acid-photodynamic therapy for the treatment of acne vulgaris: a study of clinical efficacy and mechanism of action. Br. J Dermatol 2004;151:616–22. 61. Kimura M, Itoh Y, Tokuoka Y et al. Delta-aminolevulinic acid-based photodynamic therapy for acne on the body. J Dermatol 2004;31:956–60. 62. Hwang EJ and Seo K.Topical photodynamic therapy for treatment of acne vulgairs: comparison of two IPL appli- cators and different application times of ALA. Abstract 290. American Society for Laser Medicine and Surgery Abstracts pg. 86. 63. Alexiades-Armenakas, M. Long-pulsed dye laser-mediated photodynamic therapy combined with topical therapy for mild to severe comedonal, inflammatory, or cystic acne. J of Drugs in Dermatol 5(1); 2006 January 45–55. 64. Parrish JA. New concepts in therapeutic photomedicine: Photochemistry, optical targetings, and the therapeutic windown. J Invest Dermatol 1981;77:44–50. 65. Tuchin VV, Genina EA, Bashkatov AN, et al.A pilot study of ICG laser therapy of acne vulgaris: photodynamic and photothermolysis treatment. Lasers Surg Med 2003;33: 296–310. 66. Genina EA, Bashkatov AN, Simonenko GV, et al. Low- intensity indocyanine-green laser phototherapy of acne vulgaris: pilot study. J Biomed Opt 2004;9:828–34. 67. Lloyd JR and Mirko M. Selective photothermolysis of the sebaceous glands for acne treatment. Lasers Surg Med 2002;31:115–20. 68. Paithankar DY, Ross EV, Saleh BA, et al. Acne treatment with a 1,450nm wavelength laser and cryogen spray cool- ing. Lasers Surg Med 2002;31:106–114. 69. Mazer JM.Treatment of facial acne with a 1450nm diode laser: a comparative study. Lasers Surg Med 2004:34: S67. 70. Mazer JM and Fayard V. Eighteen months results after treatment of facial acne with the 1450nm diode laser. Abstract 103. American Society for Laser Medicine and Surgery. 71. Santhanam A, Shah A and Kumar P. The 1450-nm diode laser in the treatment of inflammatory facial acne vulgaris in Indian patients – A pilot study. J Am Acad Dermatol. Abstract. P45. 72. Jih MH, Friedman PM, Goldberg LH et al.The 1450-nm diode laser for facial inflammatory acne vulgaris: dose- response and 12-month follow-up study. J Am Acad Dermatol 2006;55:80–7. 73. Bernstein EF. Lower-energy double-pass 1450nm laser treatment of acne dramatically decreases discomfort with similar efficacy as compared to standard high-energy treatment. Abstract 104. American Society for Laser Medicine and Surgery Abstracts. 74. Friedman PM, Jih MH, Kimyai-Asadi A, et al.Treatment of inflammatory facial acne vulgaris with the 1450nm diode laser: a pilot study. Dermatol Surg 2004;30:147–51. 75. Astner S,Anderson R and Tsao S. 76. Glaich A, Friedman P, Jih M, et al.Treatment of inflam- matory facial acne vulgaris with combination 595-nm pulsed-dye laser with dynamic-cooling-device and 1450- nm diode laser. Lasers Surg Med 2005;Epub. May 2005. 77. Wang SQ, Counter JT, Flor Me and Zelickson BD. Treatment of inflammatory facial acne with the 1,450 nm diode laser alone versus microdermabrasion pluse the 1,450nm laser: a randomized, split-face trial. Dermatol Surg 2006;32:249–55. 78. Lupton JR,William CM,Alster TS. Nonablative laser skin resurfacing using a 1540nm erbium glass laser: a clinical and histologic analysis. Dermatol Surg 2002;28:833–5. 79. Fournier N,Dahan S, Barneon G, et al. Nonablative remodeling: clinical, histologic, ultrasound imaging, and profilometric evaluation of a 1540 nm Er:glass laser. Dermatol Surg 2001;27:799–806. 80. Boineau D, Angel S, Nicole A, et al.Treatment of active acne with an Er:glass (1.54um) laser. Lasers Surg Med 2004;34:S55. Lasers,light,and acne 87 07 Carniol-8028.qxd 8/23/2007 10:28 AM Page 87 81. Kassir M, Newton D, Maris M et al. Er:glass (1.54um) laser for the treatment of facial acne vulgaris. Lasers Surg Med 2004;34:S65. 82. Angel S, Boineau D, Dahan S, Mordon S.Treatment of active acne with an Er:Glass (1.54 um) laser: A 2-year follow-up study. Journal of Cosmetic and Laser Therapy 2006;8:171–6. 83. Ruiz-Esparza J, Gomez JB. Nonablative radiofrequency for active acne vulgaris: the use of deep dermal heat in the treatment of moderate to severe active acne vulgaris (thermotherapy): a report of 22 patients. Dermatol Surg 2003;29:333–9. 84. Avram, DK and Fitzpatric RE.Treatment of active acne and acne scars with SmoothBeam (1,450 nm) and Thermage (radio frequency): A comparative study. ASLMS abstracts 56. 85. Retrieved from http://www.myzeno.com. 88 Clinical procedures in laser skin rejuvenation 07 Carniol-8028.qxd 8/23/2007 10:28 AM Page 88 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 50cm 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.) 08 Carniol-8028.qxd 8/23/2007 10:29 AM Page 89 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 90 Clinical procedures in laser skin rejuvenation Fig 8.2 Postinflammatory hyperpigmented macules of the cheek after resolution of active acne. 08 Carniol-8028.qxd 8/23/2007 10:29 AM Page 90 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 08 Carniol-8028.qxd 8/23/2007 10:29 AM Page 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 (CO 2 ), 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 CO 2 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 92 Clinical procedures in laser skin rejuvenation 08 Carniol-8028.qxd 8/23/2007 10:29 AM Page 92 hybrid devices include a small CO 2 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 CO 2 laser resurfacing. Using an Er:YAG laser after CO 2 laser resurfacing can remove a thin layer of debris and devitalized tissue, and speed healing. Notably, post-treatment erythema after CO 2 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 CO 2 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 Treatment of acne scarring 93 Fig.8.3 Hypopigmented cheek scars that are slightly atrophic. 08 Carniol-8028.qxd 8/23/2007 10:29 AM Page 93 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 CO 2 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. ACNE SCAR TREATMENT BY 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 1320nm Nd:YAG (Cool Touch), 14–18 1450nm diode (Smoothbeam), 19 and 1540nm Er:glass (Aramis), as well as intense-pulsed light machines with a similar range (Titan, 1100–1800nm). 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 1540nm 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. 94 Clinical procedures in laser skin rejuvenation 08 Carniol-8028.qxd 8/23/2007 10:29 AM Page 94 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. ACNE SCAR TREATMENT BY 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 1550nm 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 2–3mm 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 pigment 11 or a rolling pin may be used. Rolling is performed with a needle-studded rolling pin 33 – 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. Treatment of acne scarring 95 08 Carniol-8028.qxd 8/23/2007 10:29 AM Page 95 [...]... 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 09 Carniol-8028.qxd 108 8/23/2007 10:30 AM Page 108 Clinical procedures in laser skin rejuvenation. .. 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 heating and is used in an off-label application for cosmetic treatments The Titan produces dermal heating through the emission of near-infrared light... 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 anesthesia, or copious quantities of a dilute 0 .5% lidocaine with 1:200 000 solution, and allowing the anesthesia to sit for 20–30 minutes before commencing 08... effect to the global skin contraction 09 Carniol-8028.qxd 8/23/2007 10:30 AM Page 1 05 Nonsurgical tightening 1 05 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 Fig 9.1 This patient was being assessed midway... EV Current concepts in nonablative radiofrequency rejuvenation of the lower face and neck Facial Plast Surg 20 05; 21: 65 73 21 Alster TS, McMeekin TO Improvement of facial acne scars by the 58 5 nm flashlamp-pumped pulsed dye laser J Am Acad Dermatol 1996; 35: 79–81 22 Bowes LE, Alster TS Treatment of facial scarring and ulceration resulting from acne excorie with 58 5-nm pulsed dye laser irradiation and... Harrison-Balestra C, Elgart GW 58 5-nm pulsed-dye laser in the treatment of surgical scars starting on the suture removal day Dermatol Surg 2003;29: 65 73 24 Bekhor PS.The role of pulsed laser in the management of cosmetically significant pigmented lesions Australas J Dermatol 19 95; 36:221–3 25 Chan H.The use of lasers and intense pulsed light sources for the treatment of acquired pigmentary lesions in Asians... 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 amorphous, 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 tissue remodeling at the cellular level, and skin tightening at the cosmetic level Currently, there are two significant noninvasive skin tightening devices... 2–2 .5 mm The remaining 30% dissipates throughout the surrounding and deeper tissues, providing significant 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 deeptissue thermal effect .5, 6 A second factor in understanding the clinical effects of the ThermaCool TC is the effect on the fibrous septae within the... not be used in patients with known sensitivity to their 08 Carniol-8028.qxd 98 8/23/2007 10:29 AM Page 98 Clinical procedures in laser skin rejuvenation ZYDERM I ZYDERM 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 . 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. pulsed-dye laser, the KTP laser, and the intense-pulsed light device. 94 Clinical procedures in laser skin rejuvenation 08 Carniol-8028.qxd 8/23/2007 10:29 AM Page 94 Post-treatment effects are minimal. performed along key 104 Clinical procedures in laser skin rejuvenation 09 Carniol-8028.qxd 8/23/2007 10:30 AM Page 104 tightening points.These areas typically include the skin overlying the lateral malar