2017-18 HSC Section 4 Green Book

WU AND FITZPATRICK

combines multiple laser modalities to selectively target different aspects of the photoaged face. The ability to perform each of these treatments within a single session with good results, minimal side effects (such as transient burning, stinging, erythema, and edema), and no major adverse events is of substantial benefit to patients who require the greatest effect in the shortest time. Previous study of combined laser rejuvenation has thus far been limited. Gold and Biron used both superficial and deep fractionated CO 2 laser to safely achieve good facial rejuvenation results [14]. In this study, 15 patients experienced significant improvements in both dyspig- mentation and skin texture. A study by Kotlus examined the efficacy and safety of a combination of deep fractional CO 2 ablation and superficial fractional ablation of eyelid and periorbital skin for improvement of rhytidosis and redundancy [8]. Fifteen patients underwent dual-depth fractional CO 2 resurfacing of eyelid and periorbital skin. Optimal 6 month post-treatment improvements were noted for eyelid skin rhytidosis and redundancy. The recovery profile was excellent with no serious complica- tions noted. In a split-face study involving eight patients, Cohen and Ross found that combining fractional ablative with non-ablative treatment achieved similar clinical efficacy as ablative alone but with a more benign side effect profile [15]. Previous work published by our group demonstrated the use of CO 2 laser, Q-switched alexan- drite laser, short pulsed dye laser, and Er:YAG laser in various combinations for treatment of photoaged facial skin [16]. Several important differences exist between the present study and our previous work. Firstly, quantitative clinical measurements and blinded ratings were undertaken, and a more detailed patient response was evaluated. Additionally, our photographic standards have evolved allowing for a more reproducible and demonstrable treatment effect. Finally, treatment tech- nique and device technology has been updated to reflect current laser surgical approaches such as fractionated CO 2 resurfacing and long pulsed dye laser which were not available previously. In this study, we treat a robust number of patients with five different laser modalities in a single treatment session. The specificity of each device allows treatment that is more tailored to the individual needs of each patient. Many other studies have utilized a combination of energy devices for facial rejuvenation [7–12,17]. These studies primarily consist of a variety of pulsed light energies, non- ablative fractional lasers, and radiofrequency devices—all of which are considered minimally invasive strategies predicated on achieving acceptable efficacy while minimiz- ing downtime. In contrast, the current study involves a combination of 50–100% density superficial CO 2 ablation,

patients presented with many discrete areas of severe dyspigmentation, numerous superficial to moderately deep rhytides, moderate erythema or multiple telangiectasias, and roughness to multiple localized areas. Fig. 4. Overall clinical improvement following multi-modal sequential laser rejuvenation. Sustained overall improvement was measured at 54 36% and 59 24% at short- and long-term follow-up assessments, respectively. No significant difference was detected between the two groups. N ¼ 50, data represented as mean SD. Pre- and post-treatment photographs are shown in Figure 2. All measured clinical parameters achieved significant improvement (Fig. 3). Overall improvement was measured at a sustained 60% over the long-term (Fig. 4). Patient Satisfaction Patient satisfaction was high, measuring on average 3.1 out of 4 out of the 28 patients that responded to the survey. This correlated with a patient perceived improvement of 68% after treatment. Little or no pain was experienced during the procedure with a rating of 0.9 out of 4. Healing time was measured at 9 4 days (mean SD) and lifestyle disruption during the week immediately post-treatment was rated at 2.4 out of 4 (mild to moderate). These data are summarized in Table 1. DISCUSSION With increasing levels of technological sophistication and physician expertise, the boundaries of safe and effective facial rejuvenation continue to be expanded. In this study, we present a highly effective protocol that Clinical Efficacy of Multi-Modal Laser Rejuvenation

TABLE 1. Patient Satisfaction Survey

Patient satisfaction (mean SD)

Pain or discomfort (mean SD)

Lifestyle disruption (mean SD)

Healing time (mean SD)

Perceived improvement (mean SD)

3.1 1.1

0.9 1.1

2.4 1.5

9 4 days

68 29%

53