Chapter 132 Nonablative Laser and Light Facial Rejuvenation 405

laser also has efficacy for pigmentation as does, but the KTP laser and

IPL devices, by virtue of their broad emission spectrum, appear the most effective for simultaneous treatment of both red and brown patches.

Differences between before and after results can be subtle and not always seen easily, even in side-by-side photographic comparisons. However, the popularity of these treatments among patients and physicians strongly suggests that differences, while not always easy to quantify, are likely real.

Patient Selection

Deciding which patients are best suited for nonablative rejuvenation depends in part on understanding what they want so that it can be determined if nonablative therapy is likely to provide these results. Good candidates for nonablative resurfacing tend to be relatively young, usually 25–65 years of age, and have minimal sagging of the face. Patients should understand that skin texture will improve and fine lines in particular will be softened, not eradicated. Cumulative aesthetic benefits from nonablative resurfacing are similar in type though less in magnitude than the results of ablative resurfacing. Additionally, since changes will occur gradually, typically after three to six or more treatments, those receiving nonablative treatments should not expect dramatic results immediately.

These treatments are variably painful. The infrared sources are the most painful of these non-ablative procedures and usually require topical anesthesia for the procedures to be tolerable. Mild erythema and edema do occur following each treatment, but these sequelae remit within minutes to a few hours or may be concealed with cosmetics. Intense treatments can elicit moderate erythema and edema, which may peak 1–2 days after treatment and tend to subside a day or two later.

Infrared vs. Pulsed Dye

In general, it is important to distinguish between the infrared nonablative devices (1320 nm, 1450 nm, 1540 nm) on the one hand, and pulsed dye lasers, IPLs, and 532 and 1064 nm Nd:YAG lasers on the other. Infrared lasers, while uncomfortable, are associated with only a few hours of redness and swelling, while side effects and longer duration tissue effects are routine with the other devices.

Dark-skinned patients or those with a tendency to develop hyperpigmentation after skin injury can often safely undergo nonablative infrared therapy. The lasers are less susceptible to pigmentary complications, and patient skin color is less important when using these. With the noninfrared devices, treating tan patients is more risky, and skin color problems after treatment, more likely. Although recent evidence indicates that, in most cases, dark-skinned and Asian patients seldom develop pigmentary abnormalities after nonablative treatment, the risk of hyperpigmentation and hypopigmentation in such patients is still greater than in lighter skinned patients.

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Postoperative Care

After nonablative treatment, little if any post treatment care is usually required, except with the fractional devices where keeping the skin moist is essential to rapid comfortable healing. Unusually stringent sun protection is not necessary after nonablative therapy although patients should refrain from active sun-seeking behaviors for a few days thereafter.

Patients who prefer to continue to receive maintenance therapy for the texture and color of their facial skin will often be satisfied with nonablative resurfacing. After the standard course of three to six nonablative facial treatments separated by 3–4 week intervals, treatments can be continued indefinitely on a 3 to 4 times/year basis. Some patients may choose to receive subsequent treatment courses on different devices to obtain cumulative benefits.

Choosing a Device

Lasers and light sources should be chosen so that the features most bothersome to the patient are best addressed. Most devices are relatively specific, in that they are better for some purposes.

1.Wrinkle or acne scars do moderately well with mid-infrared lasers but better results are seen with fractional resurfacing.

2.Red color is best treated with vascular-selective KTP, long pulsed Nd:YAG, and pulsed-dye lasers and IPL.

3.Brown color is best treated with pigment-selective 532 KTP, Nd: YAG, and Q-switched lasers and IPL.

4.Texture and color, including red and brown color, can be collectively modestly improved by many different devices. IPL is a particularly effective hybrid modality, but even better textural improvement is seen with fractional resurfacing, albeit with more downtime. The infrared lasers are notable in their inability to effectively treat color.

In general, the less specific the patient objective, the greater the likelihood of satisfaction with nonablative therapy. Thus, patients who want removal of a particular feature, like redness or brown spots, or a particular wrinkle, tend to be less pleased after treatment than those interested in overall facial skin rejuvenation. Specific complaints are better treated with a laser device and setting speci c for that indication (e.g., a Q- switched laser for lentigines, or a pulsed-dye laser with purpura for a spider angioma).

Device-Specific Pearls

KTP or Frequency-Doubled Nd:YAG laser (532 nm)

Good for red, vessels, brown, and texture

Excellent for small-caliber focal facial telangiectasia and lentigines.

Full face treatments help diffuse redness, small vessels, dyspigmentation caused by lentigines and fine wrinkling.

Chapter 132 Nonablative Laser and Light Facial Rejuvenation 407

Start by tracing individual vessels then using a bigger spot the entire face is “painted.”

Pulsed-Dye Laser (585 nm, 595 nm)

Good for red, vessels, and texture

Excellent for facial telangiectasia, diffuse erythema and also appears to improve fine vessels.

Recommend a series of at least 3 treatments spaced 4–6 weeks apart.

Patients favor purpura free treatments using long pulse durations the 10 msec domain.

Intense-Pulsed Light Device (500–1200 nm)

Good for red, brown and texture

Ideal for diffuse facial improvement in color, tone and texture.

A series of 5 to 6 treatments performed monthly is recommended.

The addition of 5-ALA applied 30–60 minutes in advance of treatment optimizes improvement in color and texture as well as fine lines.

Long-Pulsed Nd:YAG laser (1064 nm)

Good for red and texture

Mid-Infared Lasers (1320 nm Nd:YAG, 1450 nm diode, 1540 nm Er:

Glass)

Best for texture, wrinkles and texture

Do not help color

A series of 5–6 treatments recommended.

Acne scarring improves better than fine to moderate wrinkles. Most see little improvement for the first 4 treatment but with the final 2 treatments in the series seem to make the biggest noticeable difference.

Pain during treatment is common, and can be somewhat mitigated with topical anesthesia.

Fractional Resurfacing Lasers

Best for brown color, acne scars, and wrinkles

A series of 4–6 treatments recommended.

Acne scarring and fine wrinkles improve better than moderate wrinkles. Improvement is seen even after one or two treatments.

Pain during treatment is common, and must be mitigated with topical anesthesia usually with additional air cooling.

Low Intensity Sources

Light Emitting Diodes treatments are painless, brief and appear to improve texture to some extent and may also improve redness.

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Laser and Light Sources for Skin Rejuvenation

Infrared Lasers

Cool Touch 1320 nm YAG

Smooth Beam 1450 nm Diode

Aramis 1540 nm Er:Glass

Visible Light Lasers

Pulsed Dye (585 nm, 595 nm)

Pulsed 532 nm (KTP)

Broad Band Light Sources

Intense Pulse Light (515–1200 nm)

Low Intensity Sources

Light Emitting Diodes

410 S.M. Lam and G.H. Leibaschoff

Delivery

We use two principal methods to deliver the medicine to the desired site: needle injection and a no-needle method of aquaporation delivery. The former method is more accurately performed with a mesogun that controls the depth and measures a standard amount of medicine delivered per pass. We use a 1/2-inch 30-gauge needle that penetrates approximately 1 mm deep near the dermal-epidermal junction. The no-needle method is a newer technology that has shown good efficacy

Perform sessions weekly for the first month then biweekly for the second month, followed by monthly treatments. The frequency in the rst 2 months is mandatory but is individualized thereafter based on age,

skin type, and treatment outcomes.

Mesotherapy provides excellent panfacial rejuvenation and can lessen wrinkles that would otherwise be unsafe to treat with Botox therapy or difficult to manage with medium-depth chemical peeling. Mesotherapy treats wrinkles that appear in animation and can soften static wrinkles somewhat.

Phosphatidylcholine

Another injectable combination, phosphatidylcholine mixed with deoxycholate, is often confused with mesotherapy. Unlike mesotherapy, which targets the dermal-epidermal junction, phosphatidylcholine/deoxycholate is administered more deeply into the fat to effect local lipolysis. Phosphatidylcholine/deoxycholate is used, but is not an equivalent to liposuction. This drug combination is marketed in Europe as Lipostabil from Aventis Laboratories. It is unsafe in the postseptal periocular region, as there have been four reported cases of blindness to date when used to treat steatoblepharon. Phosphatidylcholine/deoxycholate should only be used in experienced hands in other parts of the body, as it can cause skin or muscle necrosis if injected in improper quantities and depth. It is associated with discomfort, erythema, and edema for several days after treatment, which is expected and discussed preoperatively.