2017-18 HSC Section 4 Green Book

Review Clinical Review & Education

Energy-Based Facial Rejuvenation—Advances in Diagnosis and Treatment

Table 3. Summarized Current Clinical Practice Recommendations and Uncertainties for Discussed Diagnoses Diagnosis Current Clinical Practice Recommendation

Controversies or Uncertainties

Long-term data are lacking regarding ultrasonography and radiofrequency energy. Dyschromia is prevalent with more aggressive treatments. Surgical therapy for more advanced disease is still the gold standard. Melasma has a high propensity for recurrence even with more mild treatments; no therapy completely mitigates this risk. Dyschromia can occur more frequently with ablative fractionated lasers than nonablative lasers; however, nonablative lasers may only achieve more modest effects. More favorable results may occur by blending treatments. No laser completely mitigates the risk of dyschromia in Fitzpatrick type V and VI skin. Ultrasonography and radiofrequency may be beneficial for rhytids; however, more data are needed.

Rhytids

Mild to moderate rhytids can be managed with both ablative and fractionated lasers with greater effects but longer downtimes with ablative lasers. Ultrasonography and radiofrequency energy can improve rhytids. Both IPL and nonablative fractionated lasers are safe and effective for melasma and in combination with bleaching agents and superficial chemical peels. Fractionated lasers are safe and effective in acne scarring. They require more treatments than traditional resurfacing lasers, but have a lower adverse effect profile; however, traditional ablation can be used for severe acne scarring. Ablative resurfacing lasers are contraindicated in Fitzpatrick type V and VI skin; ablative fractionated lasers are relatively safe and effective, but have a risk of dyschromia. Nonablative fractionated lasers are the safest; however, they may require many treatments to achieve expected results.

Melasma

Facial scarring

Ethnic skin

Abbreviation: IPL, intense pulsed light.

laxity with less downtime, but studies are needed to characterize long-term benefit. 33,35,36,39 With the advent of fractionated lasers and IPL therapy, improve- ments inmildphotoaging are seeneven in combination therapywith minimal risk for adverse effects and almost no downtime. 27-29 More treatments aregenerally required toachieve satisfactory results. This safety profile makes these lasers optimal for patients with me- lasma or with ethnic skin. Similar risks do remain with both hypo- pigmentation and hyperpigmentation, to a lesser degree, and the patient should be counselled appropriately. 57-59 Limitations Thisreviewhasseverallimitations.First,werestrictedoursearchtothe past5years,withfewexceptions.Wetriedtolimitoursearchtoreports of patients receiving only energy-based therapy, excludingmany, but notall,articlesthatincludedothertypesoftherapy.Werecognizethat the articles reviewedwere extremely heterogeneous in theirmethod and type of treatment. Nouniformtreatment exists for any particular problemexamined,increasingtheriskofbiasinreviewingthesestud- ies. Finally, many studies do not possess a high level of evidence and thosethatdoareunderpowered.Werecognizethedifficultyinperform- ing a high-power, randomized study in cosmetic literature. Conclusions This review carefully assesses the current energy-based facial reju- venation techniques in the facial plastic surgeon’s armamentarium. Nonsurgicalfacialrejuvenationtechnologyhasrapidlyexpandedover the past 5 years. The focus of this technology is shifting to carefully balanceminimalrisksanddowntimewhilemaximizingoutcomes.Pa- tients should be informed about the benefits, adverse effects, dura- tionof effect, andneed for further treatments. An informeddecision must be made between the facial plastic surgeon and their patients as to theappropriate treatment.Manyof these technologies arenew, and further study is required to further elucidate optimal treatments for all conditions regarding photoaging.

lead to improvements in rhytids and acne scars in darker skin; how- ever, these are contraindicated in Fitzpatrick type V and VI skin ow- ing to the risk of dyspigmentation and scarring. 64 These risks are somewhat mitigated in patients using nonablative nonfraction- ated lasers, such as the 1319-nm PDL, 1320-nm Nd:YAG, and the 1540-nmdiodelaser,withimprovementinacnescarsandoverallscar severity, but they do not have the improvement in rhytids seenwith patients treated with more aggressive lasers. 62,63,65,66 Fractionated lasers improve safety profiles further. Nonabla- tive fractionated lasers, such as the 1440-nm Nd:YAG, 1550-nm Er laser, and 1927-nmthulium fiber laser, canmoderately improve skin texture, acne scarring and rhytids. 62,64,65 Ablative fractionated la- sers are perhaps the best balance for darker skin. These include the 10 600-nm fractional carbon dioxide laser, the 2940-nm erbium: YAG laser, and the 2700-nm Er:YSGG laser. They improve down- time over nonfractionated lasers and still have moderate power to resurface mild skin laxity and rhytids. 62 There is still risk of dyspig- mentation; however, and they should be used with caution in type VI skin. 62 Finally, other energy-based therapies includingRFand IFUS seem to be safe in darker skin. 34,67 Discussion Advances in energy-based technology for facial rejuvenation over the past decade focus primarily on reducing the adverse effect pro- file and decreasing downtime while trying to achieve effective re- sults ( Table 2 and Table 3 ). Full-field ablative resurfacing continues to lead to superior results among energy-based therapies for pa- tientswithmoderate photoaging; however, patientsmust be coun- selled about longer downtimes and higher risk of adverse effects. 16 More modest improvements are seen in fractionated lasers, with shorter down time. 11,13 Fractionated lasers show significant prom- ise in scar remodeling for both acne and surgical scars and can be used safely with minimal downtime in most patients. 43,44,46,48,49 Finally, newer techniques in ultrasonographic therapy and radio- frequency energy–based therapy have promise in improving skin

Published Online: December 1, 2016. doi: 10.1001/jamafacial.2016.1435

Author Contributions: Both authors had full access to all of the data in the study and take responsibility

ARTICLE INFORMATION Accepted for Publication: August 22, 2016.

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

jamafacialplasticsurgery.com

Copyright 2017 American Medical Association. All rights reserved.

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