Clinical Procedures in Laser Skin Rejuvenation - part 6 docx

with the potential for some degree of correction. Although the amount of correction is variable and, at times, limited, many patients cannot afford or are unwilling to spend 2–3 weeks recovering from a surgical procedure.These two devices, therefore, offer alterna- tives to traditional lifting procedures when patients can not afford the downtime and are willing to accept a lesser degree of lifting. The area of noninvasive skin tightening is still relatively new, and we, as operators, are still learning how to maximize our results. Certainly, the future will bring us further technological advancements and other new devices that will enhance our ability to perform less-invasive and noninvasive rejuvenation. REFERENCES 1. Alster TS, Garg S. Treatment of facial rhytides with a high-energy pulsed carbon dioxide laser. Plast Reconstr Surg 1996;98:791–4. 2. Khatri KA, Ross EV, Grevelink JM, et al. Comparison of erbium:YAG and carbon dioxide lasers in resurfacing of facial rhytides.Arch Dermatol 1999;135:391–7. 3. Lennox G. Shrinkage of collagen. Biochim Biophys Acta 1949;3:170–87. 4. Ross EV, Naseef GS, McKinlay JR, et al. Comparison of carbon dioxide laser, erbium:YAG laser, dermabrasion, and dermatome: a study of thermal damage, wound contraction, and wound healing in a live pig model: implications for skin resurfacing. J Am Acad Dermatol 2000;42:92–105. 5. Tunnel JW, Pham L, Stern RA, et al. Mathematical model of nonablative RF heating of skin. Lasers Surg Med 2002;14(Suppl):318. 6. Hsu TS, Kaminer MS.The use of nonablative radiofrequency technology to tighten the lower face and neck. Semin Cutan Med Surg 2003;22:115–23. 7. Fitzpatrick R, Geronemus R, Goldberg D, et al. Multicenter study of noninvasive radiofrequency for periorbital tissue tightening. Lasers Surg Med 2003;33: 232–42. 8. Ruiz-Esparza J, Gomez JB. The medical face life: a noninvasive, nonsurgical approach to tissue tightening in the facial skin using nonablative radiofrequency. Dermatol Surg 2003;29:325–32. 9. Alster TS, Tanzi E. Improvement of neck and cheek laxity with a non-ablative radiofrequency device: a lifting experience. Dermatol Surg 2004;30:503–7. 10. Fisher GH, Jacobson LG, Bernstein LJ, et al. Nonablative radiofrequency treatment of facial laxity. Dermatol Surg 2005;31:1237–41. 11. Koch RJ. Radiofrequency nonablative tissue tightening. Facial Plast Surg Clin North Am 2004;12:339–46. 12. Nahm WK, Su TT, Rotunda AM, et al. Objective changes in brow position, superior palpebral crease, peak angle of the eyebrow, and jowl surface area after volumetric radiofrequency treatments to half of the face. Dermatol Surg 2004;30:922–8. 13. Kilmer SL. A new nonablative radiofrequency device: preliminary results. In: Arndt KA, Dover JS, eds. Controversies and Conversations in Cutaneous Laser Surgery. Chicago:American Medical Association Press, 2002:93–4. 14. Ruiz-Esparza J, Shine R, Spooner GJR. Immediate skin contraction induced by near painless, low fluence irradiation by a new infrared device: a report of 25 patients. Dermatol Surg 2006;32:601–10. 15. Zelickson B, Ross V, Kist D, et al. Ultrastructural effects of Titan infrared handpiece on forehead and abdominal skin. Dermatol Surg 2006;327:897–901. 110 Clinical procedures in laser skin rejuvenation 09 Carniol-8028.qxd 8/23/2007 10:30 AM Page 110 INTRODUCTION Cumulative exposure to the sun can induce clinical and histological changes in the skin, commonly called photoaging or dermatoheliosis. This occurs primarily in patients with fair skin types (Fitzpatrick 1 to Fitzpatrick 3 skin types) who have experienced repeated solar injuries over the years, such as lifeguards and outdoor laborers. 1 Clinically,photoaging represents a polymorphic response to sun damage that manifests variably as wrinkles, skin roughness and xerosis, irregular mottled pigmentation, telangiectasias (poikiloderma of Civatte), actinic purpura, sallowness (also known as Milian citrine skin), and brown macules or solar lentigines. Besides fair skin, other risk factors for the development of photoaging include difficulty in tanning, ease of sun- burning, a history of sunburn before the age of 20, advancing age, smoking, male gender, and living in areas with high ultraviolet (uv) radiation (high altitudes). 2 Individuals who develop photoaging often have a genetic susceptibility to photodamage and can experience sufficient actinic damage to develop skin cancers such as basal cell cancer or melanoma. The areas primarily affected by photoaging include the face, the V area of the neck and chest, the back and sides of the neck, the backs of the hands and extensor arms, and, in women, the skin between the knees and ankles. Photodamaged skin typically appears attenu- ated, atrophic, scaly, wrinkled, leathery, and, in some cases, furrowed and ‘cigarette paper-like’. In persons of Celtic ancestry, photoaging can produce profound epidermal atrophy without wrinkling, making the skin appear almost translucent and making dermal structures such as blood vessels more visible. Because of its predilection for visible parts of the body, photoaging-induced pigmentation can have significant psychosocial impact on affected individuals. Unfortunately, treatment of such pigment alterations has been difficult. Each year, millions of dollars are spent by consumers seeking ‘quick-fix’ solutions for the cutaneous stigmata of aging. In 2002, more than 5 million nonsurgical and 1.5 million surgical cosmetic procedures costing more than $13 billion were per- formed in the USA. 3 We can only expect such num- bers to increase in the coming decades as our aging population expands, given increases in life expectancy and growing consumer demand for improvements in cosmetic appearance. While photoprotection with either chemical or physical sunscreens remains the mainstay of care for patients with photoaging-induced pigmentation, addi- tional topical treatments in the form of retinoids, steroids, chemical bleaches such as hydroquinone, hydroxy acids, and chemical peels are also available. Unfortunately, many of these topical treatments are only able to affect changes at the level of the epidermis, while most textural and tinctorial changes in sun- damaged skin are caused by alterations in structures in the upper and deep dermis. The introduction of laser and visible-light technology over the past 30 years has revolutionized our understanding and treatment of photoinduced pigmentation by more selectively targeting pigmented molecules and structures in the dermis without dam- aging the overlying epidermis.They have also proven useful in more directed treatment of epidermal pigmentation. In this chapter, we will review some of the more common pigmented lesions associated with 10. Laser treatment of pigmentation associated with photoaging David H. Ciocon and Cameron K Rokhsar 10 Carniol-8028.qxd 8/23/2007 10:30 AM Page 111 photoaging as well as the most current and effective laser modalities available for their treatment. SOLAR LENTIGINES Solar lentigines are the most common of pigmented lesions induced by photoaging. 4 They are macular, hyperpigmented lesions ranging in size from a few mil- limeters to more than a centimeter in diameter.They tend to be multiple and grouped and bear a predilection for sun-exposed surfaces, including the face, neck, hands, and forearms.Alternative names for solar lentigines include actinic lentigines, liver spots, age spots, and sunspots. As with photoaging, the incidence of solar lentigines increases with time, affecting more than 90% of Caucasians older than 50 years.When evaluating individuals with suspected solar lentigines, clinicians must take care in distinguishing them from ephelides, lentigo simplex, pigmented actinic keratoses, flat seborrheic keratoses, melanocytic nevi, and malignant melanoma. While they can be usually differentiated on the basis of history and clinical appearance, some cases may warrant a biopsy. Although numerous non-laser therapies have been shown to be effective for solar lentigines, including retinoic acid, mequinol, and cryotherapy, many of them require repeat applications over extended periods of time to achieve significant cosmetic improvement. In addition, lightening with topical treatment is usually temporary and incomplete, with the lesions recurring immediately following cessation of therapy.The primary advantage of laser treatment of solar lentigines is that most can be removed completely in one to three treatments, depending on the modality, which provides patients with more immediate satisfaction. The primary target in a solar lentigo is the pigment melanin. Because of the broad absorption spectrum of melanin, which ranges from 351 to 1064 nm, various lasers have been used to treat solar lentigines, most with excellent results. Lasers used in published reports include the pulsed dye (585–595nm), copper vapor (511nm), krypton (520–530 nm), frequency- doubled Q-switched neodymium:yttrium aluminum garnet (Nd:YAG) (532nm), Q-switched ruby (694nm), Q-switched alexandrite (755 nm), Q- switched Nd:YAG (1064 nm), carbon dioxide (CO 2 ) (10600 nm), and argon (488–630 nm) lasers. 4 For the purpose of this review, we will concentrate on three laser modalities widely regarded as the safest and most effective for the treatment of solar lentigines: the Q- switched ruby laser, the Q-switched alexandrite laser, and the Q-switched Nd:YAG laser. The Q-switched ruby laser (QSRL) was developed to emit light in very short pulses that is preferentially absorbed by melanin, thereby reducing damage to other skin structures. Q-switched lasers can induce both photothermal and photomechanical reactions. These lasers generate high-energy radiation that leads to a rapid rise in temperature (1000°C), resulting in evaporation of targeted pigments within the skin and vacuolization (photothermal damage).The collapse of the temperature gradient that is created between the target tissue and the surrounding tissue also causes fragmentation of the target (photomechanical damage). The use of the QSRL for the treatment of solar lentigines was described in a study of eight women with 196 solar lentigines on their forearms. 5 Therapy was delivered as a single brief pulse of 40 ns to a 4mm 2 area.A single course of treatment resulted in fading of the lesions without scarring and no recurrence within a 6- to 8-week follow-up period. Histopathological examination of biopsy specimens showed vacuolization of superficial pigmentation to a maximum depth of 0.6mm immediately after treatment. Immuno- histochemical examination of specimens stained with anti-melanocyte-specific antibodies did not indicate remaining melanocytic structures in moderately pigmented lesions. Another Q-switched laser that has been also shown to be effective for lentigines is the Q-switched Nd:YAG (QSNd:YAG) laser at 532nm.A three-center trial evaluated the effectiveness of the frequency- doubled QSNd:YAG laser (532nm, 2.0mm spot size, 10ns) in removing benign epidermal pigmented lesions with a single treatment. Forty-nine patients were treated for 37 lentigines. 6 Treatment areas were divided into four quadrants, irradiated with fluences of 2, 3, 4, or 5J/cm 2 and evaluated at 1- and 3-month intervals following treatment. For lentigines, response was dose-dependent, with greater than 75% pigment removal achieved in 60% of those lesions treated at higher energy fluences. Although mild, transient erythema, hypopigmentation, and hyperpigmentation were noted in several patients, they all resolved 112 Clinical procedures in laser skin rejuvenation 10 Carniol-8028.qxd 8/23/2007 10:30 AM Page 112 spontaneously within 3 months. No other textural changes or scarring were noted. In a subsequent study the safety and efficacy of the QSRL at 694nm and the frequency-doubled QSNd:YAG (1064 and 532 nm) lasers were compared. 7 Twenty patients with pigmented lesions (including lentigines, café-au-lait macules, nevus of Ota, nevus spilus, Becker’s nevus, postinflammatory hyperpigmentation, and melasma) were treated with the QSRL and the frequency-doubled QSNd:YAG lasers. Clinical lightening of the lesion was assessed 1 month after a single treatment.A minimum of 30% lightening was achieved in all patients after only one treatment with either the QSRL or the frequency-doubled QSNd:YAG laser. The QSRL seems to provide a slightly better treatment response than the QSNd:YAG laser. Furthermore, most patients found the QSRL to be more painful during treatment, but the QSNd:YAG laser caused more postoperative discomfort. Neither laser caused scarring or textural change of the skin. At present the QSNd:YAG laser at 532nm is favored by many clinicians for the treatment of lentigines in light-skinned individuals, while the QSNd:YAG at 1064nm is favored for individuals with darker skin types. 8 One study has recently reported the use of the Nd:YAG laser in medium skin types such as Asian skin. Chan et al 9 compared the clinical efficacy and the adverse event profile of three different lasers: the Versapulse Q-switched (VQS) Nd:YAG at 532 nm, the Versapulse long-pulse (VLP) Nd:YAG laser at 532nm, and a conventional QSNd:YAG laser at 532 nm (Medlite, Continuum Biomedical, Livermore, CA). The VLP, unlike the VQS laser, causes tissue destruc- tion purely through photothermal effects.Thirty-four Chinese patients with 68 solar lentigines on the face were treated with one of the three lasers. For the VLP laser, the spot diameter was 2mm, with a pulse dura- tion of 2ms and fluence of 9–12J/cm 2 . For the VQS laser, the spot size was 3–4mm with a fluence of 1.0–1.5 J/cm 2 .The Medlite laser system involved a spot size of 2mm, with a fluence of 0.9–1.0 J/cm 2 . The mean scores (maximum 10) for the degree of clearing achieved using both patients’ and clinicians’ assessments were 4.751, 4.503, and 4.78 for the Medlite,VQS, and VLP lasers, respectively, indicating no difference in efficacy. Our treatment of choice is the use of the Q-switched alexandrite laser (755nm), as it removes pigmentation effectively without the purpura commonly associated with the use of the QSNd:YAG at 532 nm (Fig. 10.1). With the alexandrite crystal, the laser wavelength is 755nm, which is longer than that of the ruby laser (694nm) and the QSNd:YAG laser at 532nm. Longer wavelengths penetrate more deeply into the dermis and are absorbed less readily by epidermal melanin. If the skin is irradiated with wavelengths in the 400–600 nm range, oxyhemoglobin will compete strongly with melanin for absorption of photons, and vascular damage will occur, resulting in purpura.With longer wavelengths (> 600nm), where absorption by oxyhemoglobin is substantially reduced or absent and absorption by melanin over blood pigments dominates, damage is restricted to the melanin pigment-laden structures (Fig. 10.2). In a study by Jang et al, 10 Laser treatment of pigmentation associated with photoaging 113 Fig.10.1 Removal of solar lentigines on the face of a patient with type IV skin after treatment with one session of the Q-Switched Alexandrite laser (Candela Corporation). ab 10 Carniol-8028.qxd 8/23/2007 10:30 AM Page 113 197 patients with freckles were treated with the Q-switched alexandrite laser at 8-week intervals and clinically analyzed.The Q-switched alexandrite laser was operated at 755nm, with a pulse width of 100 ns using a 3mm spot.After a single treatment, all the irradiated freckles in 64% of patients were graded as excellent. More than 76% removal of freckles required an average of 1.5 treatment sessions with 7.0J/cm 2 .No scarring, long-standing pigment changes, or textural changes were seen. The superiority of laser therapy over cryotherapy in the treatment of solar lentigines has been well described.Todd et al 11 have reported a comparative study of the frequency-doubled QSNd:YAG laser (532nm),the HGM K1 krypton laser (521nm) (HGM Medical Systems Inc., Salt Lake City, UT), the DioLite 532nm diode-pumped vanadate laser (Index Corp., Mountain View, CA), and cryotherapy. A total of 27 patients with a minimum of six lesions on the backs of their hands were enrolled in the study. Each hand was divided into four sectors, and one treatment was applied per sector.Treatment with the frequency-doubled QSNd:YAG laser involved treatment for 30ns to a 3mm spot; comparative treatments with the HGM K1 krypton laser and the DioLite 532 nm diode- pumped vanadate laser were 0.2s on/0.2 s off to a 1mm spot and 39ms to a 1mm spot, respectively. At 6 weeks after treatment, the frequency-doubled QSNd:YAG laser was found to provide superior lightening compared with other treatments. This level of response was still maintained at 12-week follow-up. From the patients’ perspective, a survey showed that they considered this form of laser therapy to produce the best results (n =18), followed by diode-pumped vanadate laser (n = 6), cryotherapy (n = 2), and the krypton laser (n = 1). The fewest adverse events were reported from use of the Q- switched laser, whereas the krypton laser had the highest number of such events. Mild transient erythema was reported for all therapies, with hypopigmentation and/or hyperpigmentation and scarring occurring infrequently. Intense pulsed light systems (IPLs) have been also shown to be effective for the treatment of solar lentigines – although less so compared with Q-switched lasers. 8 IPLs emit broadband light containing multiple wavelengths. Using various filters to include or exclude particular wavelengths, one can target various structures in the skin, depending on the wavelength emit- ted. Like Q-switched lasers, IPLs are also based on the principle of selective photothermolysis. However, IPLs are typically less predictable than Q-switched lasers, due to the wider range of wavelengths being used. Most often, the removal of lentigines by the IPL is incomplete and is an added benefit that occurs during IPL facial photorejuvenation to correct mild wrinkles, poor skin texture, and telangiectasias associated with chronic sunlight exposure. Because light from the IPL must pass through the epidermis in order to reach the dermal fibroblasts in photorejuvenation, focal melanin deposits that cause lentigines are inadvertently treated as well. Once photothermolyzed, these lesions usually turn a dark brown color and then peel off in 7–10 days. Because the wrinkle-improvement aspect of IPL generally takes 6–8 weeks to be seen, and is mild at best, much of the early patient enthusiasm for IPL stems from the eradication of solar lentigines and improvement of telangiectasias (Fig. 10.3). For those individuals seeking to improve pigmentation as well as fine, moderate, and deep rhytides on the face, ablative resurfacing with the CO 2 laser (10600nm) or Er-YAG laser (2940nm) remains the gold standard (Fig. 10.4).The chromophore for both lasers is water.The CO 2 and erbium lasers operate by 114 Clinical procedures in laser skin rejuvenation Fig.10.2 5 days post treatment of lentigines on hands with the Q-Switched Alexandrite laser (Candela Corporation).Typically,crusting is seen,without purpura. The crusted areas typically peel off within 7–10 days. 10 Carniol-8028.qxd 8/23/2007 10:30 AM Page 114 vaporizing epidermal and dermal tissue.The depth of vaporization depends on the device and number of passes, but in general, in the most aggressive ablative resurfacing procedures, one does not ablate more than 400µm of skin. One can reverse the pigmentation associated with photoaging rather effectively with ablative resurfacing, with outstanding results not only in pigmentation and lentigines, but also in deep lines and furrows. One also sees a degree of tissue tightening unparalleled with other laser devices.The down- side is the potential risk for scarring and pigmentary alteration, which in the worse-case scenario can be Laser treatment of pigmentation associated with photoaging 115 Fig.10.3 Improvement in telangiectasias and pigmentation associated with photodamage following three treatment sessions with an intense pulse light (IPL) source:(a) before;(b) after treatment.(Photographs courtesy of Elizabeth Rostan, MD.) Fig.10.4 Significant reduction in pigmentation and rhytids associated with chronic photodamage after a three-pass resurfacing procedure with the Ultrapulse CO 2 laser. ab a b 10 Carniol-8028.qxd 8/23/2007 10:30 AM Page 115 permanent as the raw skin heals. It is important to note that the erbium laser can also be used superfi- cially, with little downtime or erythema. However, these so called ‘microlaser peels’ have very little effect on pigmentation. The newest technology for the improvement of solar lentigines is fractional resurfacing with the Fraxel laser (Reliant Technologies, Mountain View, CA).This is a new concept in laser resurfacing whereby the skin is resurfaced fractionally (15–30%) in one session. 12,13 This is accomplished by the placement of an array of numerous microscopic zones of thermal damage in the epidermis and dermis, surrounded by islands of normal tissue.The normal skin left untreated serves as a reservoir for healing, allowing the skin to heal rapidly. This procedure is typically repeated four to six sessions every 2–4 weeks. In this way, one can resurface a large portion of the skin over time. Unlike CO 2 or erbium laser resurfacing, the skin is not vaporized during fractional resurfacing, and therefore there are no full-thickness wounds. Rather, the skin is photocoagulated.These photocoagulated zones of thermal damage range from 80 to 150µm in diameter and from 300 to 900µm in depth, depending on the parameters utilized (Fig. 10.5).The percentage of the skin resurfaced at one time depends on the combination of energy and final densities used. In four to six treatment sessions, one can resurface 59–84% of the skin at a setting that resurfaces 20% of the skin at a time, and 76–88% at a setting that resurfaces 30% at a time.The photocoagulated epidermis, which is referred to as MEND (microscopic epidermal necrotic debris), is extruded 3–5 days after the procedure; this is clinically manifested as first bronzing of the skin and later as fine flaking.The columns of photocoagulated collagen in the dermis serve as a stimulus for production of new collagen. One can thus achieve both epidermal and dermal remodeling over time (Fig. 10.6). The advantages to this fractional approach to resurfacing are numerous, from both a theoretical and a practical perspective. First and foremost, patients do not have open wounds, minimizing downtime. Second, anatomical areas that would generally be highly prone to complications of scarring with traditional resurfacing lasers, such as the neck, chest, and hands, can be safely and aggressively treated.Third, potential complications associated with open wounds, such as infection and hyper/hypopigmentation and scarring, are minimized. Fourth, one can potentially treat deeper dermal pathology. Fifth, water is the chromophore, so tissue interaction, both in the epidermis and in the dermis, is relatively uniform.Traditionally, with combined CO 2 /erbium laser resurfacing, one ablates tissue approximately 200–400µm during multiple-pass procedures. Any deeper treatment risks the complication of scarring.With Fraxel laser treatment, one can penetrate tissue much deeper safely, as entire epidermal and dermal ablation is not achieved.The diameter of each column of coagulated tissue is small enough to be invisible to the unaided eye and is surrounded by untreated skin, which provides a tremen- dous reservoir for healing. Because of these two factors, tissue can be coagulated within this small column as deep as 900µm safely. With the second-generation Fraxel laser (Fraxel SR 1500) employing a variable spot size, penetration as deep as 1.1 mm is possible. The coagulated epidermis is replaced within 24 hours by an influx of cells from the periphery of the treated spot, or column. 116 Clinical procedures in laser skin rejuvenation 100 µm Microscopic epidermal necrotic debris (MEND) Controlled zones of denatured collagen in the dermis Fig.10.5 Histological evaluation after fractional resurfacing with the Fraxel laser.The coagulated epidermis is referred to as MEND (microscopic epidermal necrotic debris). The MEND are extruded within a week after the procedure.It is thought that the improvement in pigmentation is related to the extruded MEND having a high melanin content.Below each MEND is a denatured column of collagen (bluish in color).These columns serve as a new stimulus for collagen production. 10 Carniol-8028.qxd 8/23/2007 10:30 AM Page 116 The current Fraxel laser is a fiberoptic laser utilizing a wavelength of 1550nm.The laser handpiece is equipped with a so-called intelligent optical tracking device that is able to calculate the speed of the operator’s hand against a background blue dye, adjusting for inconsistencies in hand speed, to place the intended number of microthermal zone in a given area.Other manufacturers have also fractionated the beams of their devices. Palomar manufactures a device that has a fractionated head allowing for delivery of fractionated laser spots in a stamping mode.A few laser manufacturers are in the process of fractionating CO 2 or erbium laser beams in hope of decreasing the patient downtime associated with ablative resurfacing while maintaining its superior results. The Fraxel laser is currently FDA-approved for treatment of periorbital wrinkles, acne and surgical scars, skin resurfacing procedures, and dermatological procedures requiring the coagulation of soft tissue, as well as photocoagulation of pigmented lesions such as lentigines and melasma. Solar lentigines on the face, and indeed anywhere on the body, can be treated. Multiple sessions are required. It is important to note that the mechanism of clearance is through nonspecific resurfacing and is not pigment-specific.Therefore, Q- switched lasers remain the gold standard for treatment of distinct lentigines. Fractional resurfacing is useful in those individuals who seek improvement of diffuse pigmentation or additionally seek improvement in texture, wrinkles, and (acne) scars. DERMATOHELIOSIS Long-term sun exposure results in wrinkled, inelastic skin that reflects a loss of collagen in the mid to upper dermis, with concomitant accumulation of elastotic material. 14,15 This process is referred to as solar elastosis, reflecting these histological changes.The elastotic material is derived largely from elastic fibers, stains with histochemical stains for elastin, and demonstrates marked increased deposition of the protein fibulin 2 and its breakdown products.The mechanism behind collagen loss in photodamaged skin may be the upreg- ulation of matrix-degrading metalloproteinases such as collagenase and gelatinases following UV irradiation of the skin. In addition, UV radiation causes significant loss of procollagen synthesis in the skin. 16 Patients with dermatoheliosis present with an over- all sallow, wrinkled complexion. Unfortunately, few topical regimens are effective in treating this condition because the pathology lies in the mid to upper dermis. Fortunately, various light-based technologies are available to help improve the appearance of patients with this common condition. Laser treatment of pigmentation associated with photoaging 117 Fig.10.6 Improvement in pigmentation,actinic keratosis and rhytides after fractional resurfacing with four session of the Fraxel laser:(a) before;(b) after treatment. ab 10 Carniol-8028.qxd 8/23/2007 10:30 AM Page 117 The gold standard for treatment of solar elastosis on the face remains ablative resurfacing with CO 2 or erbium lasers. Tissue is vaporized from 200 to 400µm. As the raw skin heals, a wound healing cas- cade is initiated in which inflammatory cells recruit dermal fibroblasts to produce new dermal collagen. This process results in an improvement of wrinkles associated with photoaging (Fig. 10.7). Both deep lines and pigmentation associated with photoaging can be drastically improved with this procedure. The potential risks are infection, scarring, and hyper/ hypopigmentation, which can at times be delayed. As mentioned above, fractional resurfacing with the Fraxel laser has been promising in the treatment of fine wrinkles, texture and dermatoheliosis. Fractional resurfacing treats photodamaged skin by targeting only a small fraction of the skin surface in each treatment session. Photodamage to the face (Fig. 10.8), neck, 118 Clinical procedures in laser skin rejuvenation Fig.10.7 Significant reduction in wrinkles associated with chronic sun damage after a multipass resurfacing procedure with the Ultrapulse CO 2 laser:(a) before treatment;(b) at 6 months’follow-up. Fig. 10.8 Reduction in pigmentation and fine lines after resurfacing with five sessions with the Fraxel laser: (a) before; (b) after treatment. (Photographs courtesy of Elizabeth Rostan, MD.) ab a b 10 Carniol-8028.qxd 8/23/2007 10:30 AM Page 118 chest, arms (Fig. 10.9), and hands has been treated successfully, as have acne scars, other scars, and various types of dyschromia, including melasma.This treatment regimen has produced more significant improvements in texture, color, and deep lines than are commonly seen with other nonablative technology. In a study conducted by Rokhsar and Fitzpatrick, 13 an improvement of 1.5 was seen in the wrinkle score following four to six sessions with the Fraxel laser, utilizing the Fitzpatrick wrinkle score, measuring wrinkles on a scale of 1–9. Dermal remodeling with IPL has been a source of renewed interest. In a study by Goldberg, 17 five patients underwent four sessions of dermal remodeling with an intense pulsed light source.All patients received a pretreatment biopsy and a second biopsy 6 months after the initial treatment.Biopsies were evaluated for histological evidence of new collagen formation 6 months after the initial treatment.While pretreatment biopsies showed evidence of solar elastosis, the post-treatment biopsies showed some degree of superficial papillary dermal fibrosis, with evidence of an increased number of fibroblasts in scattered areas of the dermis. Such changes, the author concluded, were evidence of new dermal collagen formation. Recently, investigators have reported better results by combining IPL with δ-aminolevulinic acid (ALA). However, it still appears that improvement in fine lines is subtle at best with IPL treatments. Various other lasers have been shown to induce nonablative dermal collagen remodeling, including the 1320nm Nd:YAG laser, the 1450nm diode laser, and the 1540nm Er:glass device. However, in reality, the results are often not reproducible – or are subtle at best. Because of their longer wavelengths, these lasers are more deeply penetrating and less damag- ing to the epidermis, while being minimally absorbed by melanin. They use water as a chromophore and are intended to target dermal collagen. It is generally accepted that this class of lasers is the least effective in treatment of wrinkles associated with photoaging. POIKILODERMA OF CIVATTE Poikiloderma of Civatte refers to erythema associated with a reticulate pigmentation and telangiectasias usually seen on the sides of the neck, lower anterior neck, and the ‘V’ of the chest. Civatte first described the condition in 1923. It is a rather common, benign condition affecting the skin. Many consider it to be a reaction pattern of the skin to cumulative photodamage, since the submental area, shaded by the chin, is typically spared. It frequently presents in fair-skinned men and women in their mid to late 30s or early 40s. Laser treatment of pigmentation associated with photoaging 119 Fig.10.9 Improvement in pigmentation and textural abnormalities associated with sun damage after combination treatment with the Q-switched alexandrite laser (one session) and the Fraxel laser (four sessions): (a) before;(b) after treatment. (Photographs courtesy of Richard Fitzpatrick MD.) ab 10 Carniol-8028.qxd 8/23/2007 10:30 AM Page 119 [...]... IPL, and Q-switched laser technology is that its 1550 nm wavelength laser largely targets tissue water and not melanin Improvement in pigmentation is a byproduct of general resurfacing and is not pigment-specific 10 Carniol-8028.qxd 122 8/23/2007 10:30 AM Page 122 Clinical procedures in laser skin rejuvenation ACTINIC PURPURA Actinic purpura is a benign clinical entity resulting from sun-induced damage... photoaging and chronological skin aging Arch Dermatol 2002;138:1 462 –70 16 Fisher GJ, Datta SC, Talwar HS, et al Molecular basis of sun-induced premature skin aging and retinoid antagonism Nature 19 96; 379:335–9 123 17 Goldberg DJ New collagen formation after dermal remodeling with an intense pulsed light source J Cutan Laser Ther 2000;2:59 61 18 Kim KH, Rohrer TE, Geronemus RG Vascular lesions In: Goldberg... proliferation typically ends within the first 4–8 months, although, rarely, it can last up to 12–14 months.The end of proliferation marks the beginning of the involutional phase During this phase, which may last for years, the hemangioma undergoes varying amounts of regression in size and 11 Carniol-8028.qxd 1 26 8/23/2007 10:31 AM Page 1 26 Clinical procedures in laser skin rejuvenation replacement with... usually last 1–3 weeks It is an extremely common finding in elderly individuals, occurring in approximately 11.9% of those older than 50 years Its prevalence markedly increases with years of exposure to the sun The effects of chronic sun exposure with the resultant UV-induced skin changes occur more often and are more pronounced in fair-skinned individuals than in others The purple macules and patches of... (‘portwine stains’) There are now a number of lasers that can potentially be used to treat these lesions (see the lasers listed above for hemangiomas) Start-safe parameters are used for the initial laser pulses to evaluate the clinical response and set the stage for further treatments. 26 11 Carniol-8028.qxd 130 8/23/2007 10:31 AM Page 130 Clinical procedures in laser skin rejuvenation a b Fig 11.3 (a) This young...10 Carniol-8028.qxd 120 8/23/2007 10:30 AM Page 120 Clinical procedures in laser skin rejuvenation The blue–green argon laser was the first laser system used for treating poikiloderma of Civatte Although it offered improvement, this treatment had significant side-effects, most notably scarring.The 532 nm potassium titanyl phosphate (KTP) laser introduced later was an improvement,... proliferating hemangioma will either slow or cease proliferation In some cases, this will even lead to early regression of the lesion, thereby minimizing the chance of scarring or other problems (Fig 11.1) Even hemangiomas that have thickened and are still actively growing will respond to vascular laser therapy 11 Carniol-8028.qxd 128 8/23/2007 10:31 AM Page 128 Clinical procedures in laser skin rejuvenation. .. always increase in size by proliferation (hyperplasia) during the first year of life, and involve skin, mucosa, and subcutaneous tissues to different degrees Cutaneous hemangiomas may involve only papillary dermis (superficial), deeper layers of the skin or subcutaneous tissues (deep), or both (compound) They may be focal, well-defined lesions or segmental, involving dermatome-like segments of skin. There... oriental patients Dermatol Surg 2000; 26: 743–90 10 Jang KA, Chung EC, Choi H, et al Successful removal of freckles in Asian skin with a Q-switched alexandrite laser Dermatol Surg 2000; 26: 231–4 11 Todd MM, Rallis TM, Gerwels JW, Hata TR A comparison of three lasers and liquid nitrogen in the treatment of solar lentigines Arch Dermatol 2000;1 36: 841 6 12 Manstein D, Herron GS, Sink RK, et al Fractional photothermolysis:... IPL in the treatment of poikiloderma is the pin-striping developed by some patients and associated with the use of the rectangular handpieces of IPL devices Care must be taken to use the IPL handpiece in a vertical manner in one session alternating with a horizontal manner in the next to minimize the potential for pin-striping Given that one cannot use ablative resurfacing to reverse signs of photoaging . Titan infrared handpiece on forehead and abdominal skin. Dermatol Surg 20 06; 327:897–901. 110 Clinical procedures in laser skin rejuvenation 09 Carniol-8028.qxd 8/23/2007 10:30 AM Page 110 INTRODUCTION Cumulative. photoaging and chronological skin aging. Arch Dermatol 2002;138:1 462 –70. 16. Fisher GJ, Datta SC,Talwar HS, et al. Molecular basis of sun-induced premature skin aging and retinoid antagonism with the Q-switched ruby laser and the Q-switched neodymium:yttrium– aluminum–garnet laser. A comparative study. J Dermatol Surg Oncol 1994;20:795–800. 122 Clinical procedures in laser skin rejuvenation 10