Noninvasive Approaches

A variety of noninvasive techniques now exist for rejuvenating facial skin. We can separate them into three categories: (1) improving skin texture and pigmentation, (2) rhytid ablation, and (3) skin tightening.

Improving Skin Texture and Pigmentation

Intense pulsed light (IPL) is the workhorse in this category (see Chapter 2) for diminishing dyspigmentation, telangiectasis, and background erythema. Although improvement in skin texture is not its primary function, these changes do occur.

Recently, light-emitting diodes (LEDs) have added further subjective improvement, enhancing the results of IPL and providing a molecular basis for clinical benefits. LED photomodulation uses coded pulses of low energy, nonlaser, nonthermal, light energy to stimulate mitochondrial activity, increase collagen and fibroblast production, and decrease collagenase (metalloproteinase). The currently recommended regimen is 50 seconds weekly for 8 weeks.1–3

Nonablative neodynium:yttrium-aluminum-garnet (Nd:YAG) lasers create a perivascular inflammatory response and secondary neocollagenogenesis while protecting the skin surface with a cryogen spray. Our experience with 1320 nm (Cool Touch II) (Cutera, Brisbane, California) has been generally positive with properly selected patients of all skin types, particularly for patients with mild rhytidosis and irregular facial suface contours resulting from acne scarring.4,5 They have enjoyed substantial improvement after 4 to 6 monthly treatments.

A dynamic tetrafluoroethane spray is synchronized to be applied to the skin for 30 msec with a delay of 40 msec before each laser pulse to the skin (precooling), while monitoring the skin surface temperature with a thermal sensor in the laser handpiece.6 The desired endpoint is 41 to 45°C. In a similar fashion, the depth of the treatment can be varied, applying the cryogen spray immediately following each laser pulse (postcooling). We employ one precooling and two postcooling applications in our treatment sessions. Postprocedure erythema is typically gone within 30 minutes, or less if a Natragel mask (Gel Concept, Whippany, New Jersey) is applied. Improvement in skin texture is not usually evident for 4 to 6 months after the initiation of treatment. Although recovery time is minimal, we feel that the drawbacks are the discomfort during the procedure (even with topical anesthetic), and the subtlety of the improvement.

Although we have had no experience with the 1540 nm Er:Glass laser (Aramis, Quantel Medical, Clermont-Ferrand, France), it may also be another potential nonablative tool for improving surface irregularities following acne and actinic changes.7,8

Rhytid Ablation

The selection of instrumentation, power, and density is determined by the severity and expanse of rhytidosis and the patient’s skin type. The erbium:yttrium- aluminum-garnet (Er:YAG) laser emits laser energy in the midinfrared light spectrum with a 2940 nm wavelength. This wavelength has 10 to 15 times more affinity

for water than the carbon dioxide (CO2) laser. Because its wavelength is at the peak of water absorption, it is a true epidermal ablation laser, producing only 5 to 20 m of thermal damage.9–11 Mild Er:YAG ablation may begin with topical anesthetic cream using 2 J/cm2, a pattern 3, size 4, and one pass. This technique can be used for very mild rhytidosis and has minimal downtime. Additional passes and local anesthesia infiltration can be added for more profound rhytidosis. Three Er:YAG passes will ablate about the same depth of epithelium as one pass of the CO2 laser will vaporize. Because the Er:YAG laser applications are more superficial with less transmission of thermal energy and no vasoablative properties, there is less erythema and more rapid healing; but Er:YAG laser treatments may be limited by bleeding, which rarely occurs with CO2 laser resurfacing. Although theoretically the Er:YAG laser can ablate even very marked rhytids, the CO2 laser is more effective for ameliorating severe photodamage and rhytidosis. There may also be a role for the combined use of CO2 and Er:YAG resurfacing techniques. Ablating the epithelial debris with the Er:YAG between passes of the CO2 laser may also have some benefit.

The Er:YAG laser may be used cautiously, with low fluences, on patients with darker skin types (Fitzpatrick III and IV). More darkly pigmented patients will frequently have a transient interval of postinflammatory hyperpigmentation beginning 2 to 4 weeks after the procedure. Topical antiinflammatory agents can be added after the second postprocedure week. Because the neck skin has fewer dermal appendages and reepithelializes slowly, it can also be treated, but with great caution, using lower fluences.

Perioperative Erbium:YAG Laser Care

Cleansing and lubrication are the key. Although the recovery time following Er:YAG ablation is significantly less and the sequelae less pronounced than following CO2 laser resurfacing, the same general principles are followed in the perioperative period. Showering and hair shampooing with baby shampoo twice daily and using a vinegar face wash (1 tablespoon of white vinegar in 4 cups of lukewarm water) twice daily will keep the face clean and minimize crusting. Natragel masks are applied frequently to supplement cutaneous hydration.

Intense sun protection is essential for all patients during the first 8 to 12 weeks postprocedure. Although cosmetically inelegant, zinc oxide is a total physical sun block and a soothing topical agent. We encourage our patients to use it for at least 2 weeks before they begin using makeup with a sun protection factor (SPF 15). After resurfacing, the patient’s skin is exceptionally sensitive and allergic; inflammatory reactions may be severe and can delay recovery. Our patients are instructed not to use any topical products, herbs, or botanicals without consulting us. Patients lasered in the perioral area are treated prophylactically with acyclovir 400 mg orally beginning 1 day preoperatively and continuing for 2 weeks postoperatively. If more than three passes of the Er:YAG are used, ciprofloxacin 500 mg b.i.d. is begun 1 day preoperatively and continued until the patient is reepithelialized in about 1 week.

The CO2 laser emits laser energy with a wavelength of 10,600 nm. Water is the absorbing chromophore. But

Figure 1–2 Marked rhytidosis with loss of skin elasticity and a blunting of facial contours was evident before carbon dioxide (CO2) laser vaporization (full face: three passes of 300 mJ; pattern 3, size 8, density 6; eyelids: three passes 250 mJ and 200 mJ pattern 3, size 4, density 5). CO2 laser-assisted upper lid blepharoplasty and internal brow suspension were performed at the same time. The patient has been pretreated with Botox neuromodulation of her lateral orbicularis, corrugator, procerus, depressor angulii oris, and platysma muscles.

unlike the Er:YAG, it causes tissue vaporization and dessication and 50 to 125 m of thermal damage with each pass. These effects will generate much more new collagen production than the Er:YAG and create a tissue tightening not expected with the Er:YAG. CO2 laser resurfacing can begin with one pass of 200 mJ (pattern 3, size 8, density 5 for the face). A maximum full-face treatment for a patient with marked solar damage would be three passes of 300 mJ. The higher the energy and the more passes, the greater the rhytid ablation, the more profound the tightening effect, and the longer the healing time. We do not treat the face segmentally (except for the eyelids and the upper lip) because this can leave demarcation lines. And the laser treatment is feathered inferior to the jawline by oblique applications or use of the Er:YAG. However, each segment of the face can be treated differently, with different pattern sizes, power, and densities.9 Areas of more solar damage, rhytidosis, and actinic keratoses can be treated with higher fluences and more passes. The eyelids are treated with lower fluences and fewer passes (see Chapter 9). Applying a Natragel mask between CO2 passes

combined with Er:YAG ablation of debris appears to have beneficial effects on the postprocedure recovery (Figs. 1–1A,B; 1–2; 1–3; 1–4A,B; 1–5A,B).

Perioperative Carbon Dioxide Laser Care

Following full-face CO2 laser resurfacing the care is generally the same as following Er:YAG laser ablation, but more intense and the sequelae more dramatic.

During the first postoperative week, our standard protocol consists of applications of CU3 copper peptide cream four times daily with twice daily vinegar washes (1 tablespoon of white vinegar in 4 cups of lukewarm water). After the first postoperative week, Natragel mask applications are better tolerated and can be applied over CU3 cream (Fig. 1–3). Protective makeup (with a physical sun block) is begun when epithelialization is complete and no crusting is apparent. Until that time the use of zinc oxide is encouraged. It is critically important that the patient has been emotionally prepared for several months of postprocedure erythema and instructed not to use any skin care products, herbs, or botanicals without having first discussed them with our staff.

All patients are treated prophylactically with acyclovir 400 mg q.i.d. and ciprofloxacin 500 mg b.i.d., beginning 1 day preoperatively and continued for 1 to 2 weeks postoperatively until they are completely reepithelialized. One dose of fluconazole 150 mg is given 1 day preoperatively.

Figure 1–3 Two months after CO2 laser resurfacing, moderate generalized erythema persisted. Six months later much of it has dissipated. Improved texture and contour are evident.

Skin Tightening

The results of CO2 laser resurfacing are the gold standard of nonincisional skin tightening (see earlier section) but a significant recovery period is required. A new generation of instrumentation utilizing radiofrequency energy has introduced the possibility of skin tightening without downtime (see Chapter 3, radiofrequency

section). These techniques do not primarily ablate rhytids, but by tightening the cutaneous surface, we have seen improvement of skin folds and acne scarring (Figs. 1–6A,B; 1–7A,B).

Since modifyings our treatment protocols by reducing the power of each application with the ThermaCool (Thermage Inc., Hayward, California) system outcomes have improved significantly.

Patient Preparation

We pretreat the patients with Botox 2 weeks before their “therma-lifting” procedure. If we are treating the forehead, we prepare the area with a neuromodulated brow lift. If we are treating the face and neck, we pre-

pare these areas with neuromodulation of the platysma. In both cases relaxation of the muscles that depress the brow and the lower face in theory decrease resistance to collagen contraction and allow more efficient collagen remodeling.

Face Treatment Protocol

First pass: setting 13.5; complete coverage

Second pass: setting 13.5; two rows of preauricular coverage

•Two rows above the jawline

•Two rows below the jawline

•One row from the corner of the mouth to the inferior tragus

•One row from the superior aspect of the nasolabial fold to the superior tragus

Third and fourth passes: setting 12.5; same passes as above

Forehead Treatment Protocol

First pass: setting 13.5; complete coverage

Second and third passes: setting 12.5; complete coverage

Neck Treatment Protocol

First, second, and third passes: setting 12.5; submental and lateral aspect of neck, avoiding midline

References

1.McDaniel DH, Newman J, Geronemus R, Weiss RA, Weiss MA. Nonablative nonthermal LED photomodulation: a multicenter clinical photoaging trial [abstract 72]. American Society of Laser Medicine and Surgery annual meeting, Anaheim, California, April 2003.

2.Geronemus R, Weiss RA, Weiss MA, Newman J. Nonablative LED photomodulation: light activated fibroblast stimulation clinical trial [abstract 73]. American Society of Laser Medicine and Surgery annual meeting, Anaheim, California, April 2003.

3.Weiss RA, Weiss MA, McDaniel DH, Newman J, Geronemus R. Comparison of nonablative fibroblast photoactivation with and without application of topical cosmeceutical agents [abstract 74]. American Society of Laser Medicine and Surgery annual meeting, Anaheim, April 2003.

4.Goldberg DJ. Subdermal resurfacing. Operative Techniques in Oculoplastic, Orbital and Reconstructive Surgery 1999; 2:188–193

5.Bosniak S, Cantisano-Zilkha M. A combined approach to noninvasive facial rejuvenation: home care, peels, neuromodula-

General Treatment Principles

1 Applications not overlapped

2.Allow at least 2 minutes before re-treating an area

3.Use lower power settings when applying multiple passes

4.Pinch skin between fingers in direction of desired tightening

5.Limit multiple passes to 5

6.Apply Natragel mask following completion of treatment

7.Re-treatment in 6 months when necessary

Conclusion

It is apparent that a variety of nonablative techniques and treatments when used concomitantly can cause a significant improvement in facial skin texture and appearance. As other modalities become available, our menu of noninvasive therapies will expand.

tion, and laser-assisted subsurface collagen remodeling. Operative Techniques in Oculoplastic, Orbital and Reconstructive Surgery 2001;4:65–68.

6.Goldberg DJ. Full-face nonablative dermal remodeling with a 1320 nm Nd:YAG laser. Dermatol Surg 2000;26:915–918

7.Fournier N, Dahan S, Barneon G, et al. Nonablative remodelling: clinical, hisologic, ultrasound imaging, and profilometric evaluation of a 1540 nm Er:glass laser. Dermatol Surg 2001;27:799–806

8.Lupton JR, Williams CM, Alster TS. Nonablative laser skin resurfacing using a 1540 nm erbium glass laser: a clinical and histologic analysis. Dermatol Surg 2002;28:833–835

9.Hruza GJ. Laser skin resurfacing. Arch Dermatol 1996; 132:451–455

10.Goldberg DJ. Er:YAG laser resurfacing: what is its role? Aesthetic Surg J 1998;18:255–260

11.Bosniak S. Laser resurfacing. In Bosniak S, Cantisano-Zilkha M. Cosmetic Blepharoplasty and Facial Rejuvenation. Philadelphia: Lippincott–Raven; 1999.