2017-18 HSC Section 4 Green Book

Review Clinical Review & Education

Energy-Based Facial Rejuvenation—Advances in Diagnosis and Treatment

fined a 5-year constraint. 4 Our primary search used the terms sum- marized in Table 1 , andwe also included 14 articles that we deemed landmark articles publishedbefore2011.We restrictedarticles tohu- mandatareportedintheEnglishlanguage.Wescreenedarticlespub- lished between January 1, 2011, and March 1, 2016, and focused on randomized clinical trials (RCTs), meta-analyses, systematic re- views, and clinical practice guidelines, including case-control stud- ies, case studies, and case reports when necessary. These searches generated 692 articles, and all abstracts were reviewed. We se- lected articles for full reviewthatwere deemed to providemajor ad- vances in the diagnosis or treatment of laser and light treatment ( Figure 2 ). Articleswere excluded if therewas only histologic analy- sis, clinical analysis was lacking, primary therapies were non– energy based or invasive, they were nonsystematic reviews, they contained technological evaluation unrelated to therapy, or the therapy was not applicable to facial rejuvenation. We considered sources of bias in these articles and defined areas of uncertainty as those in which the evidence conflicted. Full-field ablative or traditional laser resurfacing removes the en- tire skin surface in the area being treated with depth of injury de- pending on energy level. Ablative skin resurfacing was popularized in the 1990s after the introduction of pulsed carbon dioxide sys- tems. At that time, carbon dioxide laser was largely used for treat- ment of acne scarring and facial rhytids. This technique continues to be used to treat severe acne scarring and moderate rhytids with a high degree of patient satisfaction, as well as to treat prolonged erythema and pigmentation issues. 5 The introduction of the er- bium yttrium aluminum garnet (erbium:YAG) laser allows for mini- mal thermal damage and quicker postoperative healing with the tradeoff of decreased tissue tightening. 6 Newer erbium:YAG lasers (Contour TRL) use a simultaneous combination of ablative and nonablative resurfacing for severe perioral rhytids to minimize re- covery timewhilemaximizing benefit of each individual treatment. 7 Full-field resurfacing is great tool for improvement in patients with moderate photoaging and rhytids who arewilling to undergo a lon- Advances in Treatment Skin Rejuvenation

ger downtime for the benefit of a single treatment. Clinical experi- ence by the senior author (B.C.M.) and colleagues confirm that ex- tensive facial resurfacing with a tunable erbium:YAG laser can be performed with dramatically reduced risks of hypopigmentation, scarring, or postinflammatory hyperpigmentation. Fractional laser resurfacing treats a small “fraction” of the skin at each session, leaving skip areas between each exposed area. Frac- tional ablative resurfacing with carbon dioxide was initially de- scribed in 2007. 8 Carbon dioxide fractionated resurfacing im- proves photodamage by approximately 50%, with downtime generally limited to 1 week and an improved adverse effect profile overfull-fieldresurfacing. 9,10 erbium:YAG,yttrium-scandium-gallium- garnet (YSGG) and Er:YSGG (2790-nm) systems were introduced with the intent of providing more significant results than nonabla- tive fractional systems while achieving shorter healing times and complicationswhen comparedwith full-field ablative systems. 11 er- bium:YAG lasers can be used inmultiple sessionswith increased flu- ence to increase improvement in photoaging without increasing down time while also increasing the amount of new collagen formation. 12 One study showed a 26% to 75% improvement in photoaging with multiple passes and a higher fluence with only Key Points Question What advances in diagnosis, prevention, and management of energy-based facial rejuvenation have been introduced in the past 5 years? Findings In this systematic review, facial rejuvenation treatments and devices that focus on decreasing adverse effects and improving downtime were identified: lasers, light therapy, and non–laser-based thermal tightening. Meaning Improved efficacy and safety with nonablative fractioned lasers and intense pulsed light has led to improved options with minimal downtime for patients with mild to moderate degree of photoaging; however, full-field resurfacing remains important for more severe photoaging and facial rhytids.

Figure 1. Light SpectrumWith Common Laser Wavelengths and Absorption Peaks for Common Molecular Targets Superimposed

Hemoglobin Melanin Water Scatter

IPL

Diode, 1450 nm

Pulsed dye

Nd:YAG, 1320, nm

Erbium: Glass, 1540 nm

KTP

Nd:YAG, 1064 nm

Absorption

300

500 600 700 800 900

1000

1500

3000

5000

20000 10000 7500

400

Mid-infrared

Ultraviolet

Near-infrared

Adapted from Lumenis. IPL indicates intense pulsed light.

Wavelength, nm

(Reprinted) JAMA Facial Plastic Surgery January/February 2017 Volume 19, Number 1

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