2017-18 HSC Section 4 Green Book

Review Clinical Review & Education

Energy-Based Facial Rejuvenation—Advances in Diagnosis and Treatment

types III or V who were treated with erbium:YAG nonablative frac- tional resurfacing treatment, with 1 patient experiencing mild hy- popigmentation and 1 patient experiencing postinflammatory hyperpigmentation lasting longer than 3 months. 46 Improvements in surgical and traumatic scarring are also abun- dant. Keaney et al 47 looked at pulsed dye laser (PDL) vs potassium titanyl phosphate (KTP) laser for the treatment of erythematous sur- gical scars in a randomized study showing significant improvement in both groups and only more significant improvement in vascular- ity in the KTP arm without significant adverse effects. In a study 48 lookingatnonablativevsablativefractionallasertreatmentsforpost- thyroidectomy scars, no difference was seen between the 2 sys- tems, but the nonablative systemwas better for lightening color and the ablative system was better at decreasing hardness arguing for a combined approach. Another study 49 looked at the difference be- tween PDL and carbon dioxide ablative fractional lasers and signifi- cant improvement in both groups, but there was no statistical dif- ference between the 2 groups. The PDL group was superior in improvementofvascularityandpigmentation,andtheablativegroup was superior in pliability and thickness. Melasma Several different laser and light therapies are available for the treat- ment of melasma. Intense pulsed light safety and efficacy was ex- aminedina10-weeksplit-facestudyusingatriplecombinationcream (Tri-lumaCream,GaldermaLaboratoriesLP)vsplacebo.Resultswere improved at 10 weeks vs placebo, but the active ingredient group hadmore skin irritation. 50 A randomized open label study was per- formed for refractorymelasma comparing IPLwithbleaching agents and sunscreen alone vs in conjunction with IPL. There was signifi- cant improvement in themelasmagroupout to 1 year comparedwith the control group with only 1 session of IPL. 51 Similarly, nonablative fractional lasers were compared with triple topical therapy (hydro- quinone, 5%; tretinoin, 0.05%; and triamcinolone acetonide cream, 0.1%) with comparable efficacy, and the authors stated that laser treatment should be considered if topical bleaching is ineffective or cannot be tolerated. 52 Fractionated lasers on decreased settings can be effective and safe with both ablative and nonablative techniques. 53 Q-switched neodymium-doped yttriumaluminumGarnet (QS-Nd:YAG) laser vs hydroquinone for the treatment ofmelasmawas compared in a ran- domizedsplit-facestudywithimprovedpatientsatisfactionandlight- ening of the QS-Nd:YAG treated side; however, all patients had re- currenceof theirmelasma at 12weeks after treatment. 54 Comparing QS-Nd:YAG with glycolic acid peels, improvement in the melasma area and severity index (MASI) score in the QS-Nd:YAG group was seen, and, when the treatments were combined, there was supe- rior improvement objectively in the group using the modified MASI. 55,56 QS-Nd:YAGand IPL combination therapy comparedwith QS-Nd:YAG alone and IPL alone showed an improvement over QS-Nd:YAG alone and IPL alone with combination therapy; however, recurrence was still an issue. 57,58 Pulsed dye laser with triple-combination therapy was com- pared with triple-combination therapy alone in a split-face study showing improvement in the MASI on the combination side with statistically significant improvement at the 2-month follow-up visit; however, postinflammatory hyperpigmentation (PIH) did occur. 59 Fractional laser therapy using both ablative and nonablative lasers

improvement compared with surgical techniques and should be counseled appropriately. 31 Ultrasonographic therapy (MFU or IFUS) works by creating pre- cisionmicrowoundsinthedermiswithoutaffectingtheepidermiswith varied high-frequency ultrasound waves. 32 It is very effective in thin patients with mild to moderate skin laxity with proven results both subjectively and objectively, and it is safe in all Fitzpatrick phototypes. 33,34 In one study 35 using computer-assisted measure- ments, 63.6%had improvement in their skin laxity; while only 12.2% of patients with body-mass index, calculated as weight in kilograms divided by height in meters squared, greater than 30 had improve- ment at 3 months. A study examining IFUS (Ulthera system, Ulthera Inc)fortighteninginfraorbitallaxitywith1to2treatmentsshowedim- provement inall patients at 6months. 36 Ina similar study, 67%of pa- tients undergoing 1 treatment of MFU had improvement in skin lax- ity at 6 months. 37 Intense focused ultrasonography has significant promise as a nonsurgical therapy for skin and pore tightening, 38 but long-term outcome data are still lacking. Radiofrequency works by using the natural electrical resis- tance of the tissues to convert that energy into thermal energy. Both monopolar and bipolar forms of this technology are available. Re- sults are again limited by follow-up, but have shown improvement comparedwithbaseline.Inonestudy 31 comparingtheRFdevicewith traditional surgical face-lift, improvements weremodest; however, patients had a high degree of satisfaction in both groups. In an- otherstudy 39 lookingatbipolarradiofrequencytighteningoftheface and neck, 14 patients underwent a series of 4 to 6 weekly treat- ments, and their outcomes were measured by 3 blinded physi- cians. All patients reported experiencing improvement. Modest im- provementsindyschromiaandskintexturearealsoreported. 40 Taub et al 41 examined patients undergoing 6monopolar treatments over six months and showed an average of 30% patient improvement at 1 year since the first treatment, the longest follow-up to date. Ob- viously, additional studywith amore validated approachwill be very helpful in evaluating this technology. Scar Treatment Ablative fractionated lasers are used to successfully treat acne scars, including severe scars on a variety of anatomic locations. Treat- ments are typically performed as a single procedure owing to their robust clinical results compared with nonablative fractional lasers. 42,43 In a study by You et al, 44 resurfacing carbon dioxide and erbium:YAG lasers were compared with fractional lasers, both ab- lative and nonablative, and results were measured by blinded in- vestigators. They found that carbon dioxide lasers causedmore hy- perpigmentationanderythema, and that all resultswere comparable with the exception of less dramatic results in the nonablative group. They also found that that 3 ablative fractionated laser treatments were equivalent to the resurfacing lasers with shorter downtime periods and less adverse effects. 44 Nonablative fractional lasers can be successfully used in the treatment of various forms of scarring, including acne scarring, with a very favorable safety profile. Alster et al 45 showed impressive re- sults with mild to moderate acne scarring; 87%of patients who re- ceived 3 treatments at 4-week intervals showed at moderate im- provement in the appearance of their acne scars. Nonablative fractional lasers can also be safely used to treat acne scarring in darker-pigmented patients. A study of 22 Korean patients with skin

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

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