2017-18 HSC Section 4 Green Book

Clinical Review & Education Review

Energy-Based Facial Rejuvenation—Advances in Diagnosis and Treatment

fects comparedwithdeeper, purely ablative lasers. 18,19 The2790nm erbium:YSGG laser (Pearl; Cutera), an ablative laser with mild ther- mal coagulation showed significant improvement in patients with rhytids and fine lines to the 2-yearmarkwithout adverse effects and minimal downtime. 20 The combined effects of ablative and nonab- lative fractional lasers allow for a higher degree of rejuvenation than the nonablative lasers while maintaining less downtime than full- field ablative fractional lasers. Multiple sessions are, however, still required. Non–Laser-Based Skin Rejuvenation The nonlaser, light systems used for nonablative rejuvenation are groupof devices that emitwavelengths in the visible (400-760nm), near-infrared(760-1400nm),ormid-infrared(1.4-3μm)ranges.Both IPL and light-emitting diodes (LEDs) are in this group. These mo- dalities induce dermal remodelingwithout epidermal ablation.Most investigators believe that photothermal heating of the dermis both increases collagen production by fibroblasts and induces remodel- ing of the dermal matrix. Intense pulsed light was first described for the treatment of rhytids and photodamaged skin in 2000. 21,22 In amulticenter study in 2004, IPL showed significant improvement in patient’s evalua- tionof the elastosis score at the6-month follow-upwithminimal ad- verse events andnodown time. 23 Because of their safety profile and lack of down time, they are often used in combination with other lasers to enhance rejuvenation. Large series show that hyperpig- mentation is possible, but only in a small proportion of patients (2.96%). 24 FractionatedIPLandpulseinpulseIPLmaymitigatesome risk of hyperpigmentation from IPL and thus may be safer in patients with melasma. 25,26 An erbium:YAG laser alone was compared with a combination erbium:YAG laser with IPL treatments and showed improvement in the Fitzpatrickwrinkle scale inbothgroups but a showedgreater im- provement in pigmentation in the combination group. 27 In a split- face study looking at IPL and nonablative fractional laser treatment alone and in combination for photoaging, the treatment in combi- nation proved statistically superior with no increase in adverse outcomes. 28 Combination therapy of IPL and fractional erbium: YAG laser treatment compared with IPL alone in a split-face study showedglobal improvement inpigmentation, pore size, rhytids, and skin texture in all groups compared with base line with significant improvementinthecombinationtherapycomparedwithIPLalone. 29 These studies showthat the IPL incombinationwithother laser tech- niques can improve skin clarity with a minimal adverse effect profile or additional down time. 30 Non–Laser-Based Skin Tightening All nonsurgical skin-tightening devices work by delivering thermal energy to the skin or underlying structures. This creates immedi- ate mechanical contraction of collagen fibers and delayed bio- chemical remodeling and neocollagenesis via the wound-healing response. New therapies available include radiofrequency (RF) and intense focused ultrasonography (IFUS) or microfocused ultrasonography (MFU). Nonsurgical skin tightening is best suited to patients with mild to moderate skin laxity and photoaging, or extrinsic aging, without significant underlying structural ptosis. Patients with underlying structural and excessive skin laxity with deep rhytids from intrinsic aging are likely to have limited

Table 1. PubMed Search Terms and Citations Search Term

Articles, No.

Laser facial rejuvenation Fractionated laser facial Laser skin tightening

153

52 71 21 36 44

Intense pulsed light facial rejuvenation Radiofrequency facial rejuvenation

Ultrasonographic rejuvenation

Scar facial laser

140

Ethnic skin and facial laser, laser, or rejuvenation

36

Laser melasma

139 692

Total

Figure 2. Summary of Literature Review for Energy-Based Facial Rejuvenation Keywords and Selected Articles

692 Medical records identified through database searching

14 Landmark and other articles

226 Potentially relevant articles

98 Excluded not relevant to review

128 Full-text articles assessed for eligibility

Full-text articles Invasive or nonenergy 5 Based technique 3 Histologic only 2 Review 50 Insufficient data 2 Focus not applicable

62

66 Studies included in quantitative synthesis (meta-analysis)

a3- to4-daydowntime. 13 The tradeoff of these lasers comparedwith full-field ablative lasers is the need for multiple sessions to achieve similar results. The first nonablative fractional laser was the Fraxel device (Reliant Technologies Inc [now Solta, a subsidiary of Valeant Pharmaceuticals]). 2 Similar to ablative lasers, these devices primar- ily target dermal water, which causes collagen heating and dermal remodeling. Unlike their ablative counterparts; however, epider- mal injury and tissue vaporization do not occur owing to the con- comitant application of epidermal cooling. Several different nonab- lative, fractional lasers are nowusedwith promising results, with an improvedsafetyprofile. 14 Thelong-pulsedNd:YAG(LPND)hasshown modest improvement in rhytids and photoaging with erythema re- solving almost immediately after treatment. 15 These lasers tend to havemoremodestresultsandaregearedtomild-to-moderatephoto damage and solar lentigines but allow for quick recovery with little risk. 16,17 These lasers can also be used for resurfacing in darker skin types—a major advance in treating nonwhite patients Newer techniques involve the use of fractionated lasers with both ablative and nonablative properties with reduced adverse ef-

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