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  1. 1. LASERs for Face Rejuvenation Dr. Christofer Tzermias Dermatologist Director Invasive Dermatology Dept Athens Medical Center Athens - Greece
  2. 2. • Laser use on the skin has become one of the most popular methods for achieving a younger and smoother facial appearance • Unfortunately, the increasingly widespread availability of cosmetic laser therapy coupled with attendant publicity has created extraordinary, often unrealistic expectations. • Proper patient selection and assessment of each individual’s skin is crucial prior to determining whether an ablative or a non-ablative procedure is indicated. Face Rejuvenation: Ablative or Non-ablative?
  3. 3. Laser Skin Interaction • Laser light is monochromatic, coherent and collimated. • Generates high fluence. • Reflected, Scattered, Transmitted, Absorbed • Absorbed energy – Thermal energy Clinical effect & collateral damage • Ultrashort pulses of high energy Ablate or do not ablate the epidermis Dermal wounding Thermal effect: significant or minimal
  4. 4. • The Carbon Dioxide Laser has long been the “gold standard” for ablative resurfacing. • Results from traditional CO2 systems have been dramatic for severe photo-damage, but patients need to be aware of associated downtime requirements and the risk of pigmentation alteration in darker skin types. • Newer technologies, including Er: YAG Laser systems and Fractional Lasers, can offer shorter recovery times and improved safety in a broader spectrum of skin types. Ablative Laser
  5. 5. Remodelling Phase Extinction of Inflammatory Infiltration Matured Collagen fibres Increase of Collagen Fibre Strain New Elastic fibres Ablative Laser: Mechanism of action Acute Thermal Damage Phase (48-72 hours) Oedema Release of chemical mediators Collagen Shrinkage Proliferation Phase (30 days) Fibroblastic Recruiting New dermal matrix molecules New collagen fibres
  6. 6. 2.2. Collagen StimulationCollagen Stimulation 11. Fibres. Fibres ShrinkageShrinkage 3.3. RemodellingRemodelling Time1st d 30th day ShrinkageShrinkage New collagen formationNew collagen formation Vaporization Thermal Damage Healing HealingHealing 2nd d
  7. 7. Preoperative patient evaluation for Ablative Laser use Is the patient taking isotretinoin or immunosuppressive medication? What is the patient’s skin type? Does the patient have a history of cold sores? Is the patient prone to acne breakouts? Does the patient have a tendency to form hypertrophic scars or keloids? Does the patient have realistic expectations of the procedure?
  8. 8. Preoperative care for Ablative Laser use • Pretreatment regimen: broad-spectrum sun-screens, tretinoin and/or glycolic acid creams, prophylactic oral antibiotics, and antiviral medications. • Topical lightening agents: hydroquinone, kojic acid, azelaic acid, can also be used to reduce postinflammatory hyperpigmentation.
  9. 9. Postoperative care for Ablative Laser use • Wound care: dilute acetic acid or saline soaks every 2-4 h followed by bland emollients are essential for proper healing • Medications : continuation of oral antibiotics and antiviral drugs; short-term pain medications should be given in necessary • Follow-up: post-laser follow-up in the office at 2-5 days is valuable to note the quality of the patient’s wound care and the progress of wound healing.
  10. 10. Side-effects and complications of Ablative Laser skin resurfacing • Side-effects Transient erythema Localized edema Pruritus • Mild complications Prolonged erythema Milia Acne Contact dermatitis
  11. 11. Side-effects and complications of Ablative Laser skin resurfacing • Moderate complications Pigmentary change Infections (bacterial,fungal,viral) • Severe complications Hypertrophic scar Ectropion
  12. 12. Ablative Laser: Considerations in darker skin • Fractional ablative lasers can be used in a conservative fashion to treat advanced damage. • Pre-and post-procedural sun protection and bleaching creams can minimize the risk of postinflammatory hyperpigmentation. • In the post-laser period, short-them use of a medium potency steroid cream may also reduce the hyperpigmentation risk. • If postinflammatory hyperpigmentation develops, glycolic acid peels and microdermabrasion can hasten resolution. • Nonablative technologies are considered first- line because of a lower risk of postoperative complications.
  13. 13. Nonablative Laser Face Rejuvenation • Nonablative lasers heat the papillary and reticular dermis, without damaging the epidermis, to stimulate collagen synthesis. • Compared with ablative procedures, nonablative resurfacing provides more modest improvements, but with essentially no downtime and an excellent safety profile. Nonablative lasers attempt to heat and stimulate the wound healing process in the dermis, but without removing epidermis.  • This is often referred to as subsurface resurfacing. 
  14. 14. Nonablative Lasers: Pretreatment considerations • Nonablative technology is not a replacement for ablative laser resurfacing • Overall appearance of the skin will be improved, because lines and textural differences will be softened, but not eradicated • Skin changes are usually subtle and gradual • A number of treatments is required, over a period of months before the full benefits can be appreciated • A total of 3-6 sessions is usually required, at 3- 4 week intervals
  15. 15. • Proper patient selection and assessment of each individual’s skin type is crucial. • It is imperative to identify the key goals of the patient, such as an improvement in color, texture, or wrinkling, expected timeframe or number of procedures, and patient tolerance for recovery.  • The physician should explore whether a patient may tolerate multiple treatments in order to achieve the primary goal   Nonablative Lasers: Pretreatment considerations
  16. 16. Nonablative Laser Rejuvenation   • Initially, available lasers were used to achieve nonablative resurfacing, such as the PDL and Nd:YAG lasers. • Longer wavelengths, improved epidermal cooling devices, and fractional technology have expanded the armamentarium of devices available. 
  17. 17. Nonablative LASERs available • 595-nm Pulsed-dye • 1064-nm, 1320-nm Nd:YAG • 1450-nm Diode • 1500- 1540- 1550 nm Erbium:glass
  18. 18. • The exact mechanisms of non-ablative dermal remodeling are still under investigation; however, a subthreshold laser-induced injury to the dermis and/or the dermal vasculature theoretically results in a wound repair response, fibroblast recruitment and stimulation, and collagen reformation. • Because thermal energy is the source of this injury, most non ablative devices target water, the major component of the dermis, which is heated through the process of selective photothermolysis. Nonablative Mechanism of action
  19. 19. To reach these dermal targets, non-ablative devices typically rely on wavelengths in the mid-infrared regions of the electromagnetic spectrum.
  20. 20. Electromagnetic Spectrum. Ultraviolet X-Ray AM Radio Microwave Nd:YAG (1064) Smoothbeam (1450) Pulse-Dye(595) TV and FM RadioAlexandrite(755) I2PL (530-950) Visible Light Nanometers Invisible Light
  21. 21. • Non-ablative laser devices exert their effects by inducing dermal collagen remodeling while sparing the epidermis. • The remodeling process is achieved by producing thermal energy in a controlled and precise fashion, which recruits fibroblasts and stimulates collagen production. Dermal remodeling
  22. 22. • In theory, dermal heating should be aimed at tissue 100-500 μm below the skin surface.  • More superficial injury may be ineffective and result in epidermal injury, whereas deeper injury may result in scarring.  • Too much dermal injury, even within this zone, may result in irreversible damage to the microvasculature and dermis, resulting in necrotic tissue that cannot be regenerated.
  23. 23. Depth of penetration as a function of a laser wavelength (Nelson et al 2002) Laser Wavelength μwater Depth of (nm) (per mm) penetration (μm) Diode 980 0.0448 32000 Nd:YAG 1064 0.0177 81100 Nd:YAG 1320 0.204 7000 Diode 1450 3.04 470 1540 1.18 1200 Er:YAG 2940 1220 1.20 CO2 10600 84.40 17 μwater :absorption coefficient Each type of laser is associated with a different depth of penetration.
  24. 24. Patients should be reminded • The maximum collagen remodeling occurs 30-90 days after • May like the immediate post look (attributable mainly to edema). But this end-result is possible after multiple treatments • Maintenance therapy can be performed 3-4 times per year
  25. 25. Adverse events associated with Nonablative Lasers (1/3) Adverse event Comments Pain Depends on device, more so with deep- infrared devices that target water Erythema Usually clears in hours, but can last several days. This is expected endpoint with Fraxel re: store Edema Usually clears within 24h. May last longer with Fraxel re: store
  26. 26. Adverse events associated with Nonablative Lasers (2/3) Adverse event Comments Purpura Most Commonly occurs with PDL. Transient purpura may be obtained when treating telangiestacia. For photo-aging: lower fluence or lengthen pulse duration Crusting Indicates too much epidermal heating Blistering Indicates too much epidermal heating: may result in scarring
  27. 27. Adverse event Comments Infection Query patient as to history of prior HSV infection. Consider Staphylococcus aureus infection if epidermis is inadvertently ablated Dyspigmentation Most common in darker skin types. Correct amount of epidermal cooling should be used. Textural scarring Rare Adverse events associated with Nonablative Lasers (3/3)
  28. 28. Nonablative Lasers: Considerations regarding ethnic skin • The advent of nonablative lasers makes ethnic skin , a candidate for laser treatment • Although protective, the presence of melanin makes it more difficult to treat photo-aging. • Melanin absorption of laser energy can result in epidermal damage and decrease the amount of energy that reaches the intended dermal chromophores. • Because the absorption coefficient of melanin decreases as wavelength increases, near- infrared and infrared wavelengths can best provide nonablative rejuvenation for darker skin types.  • Epidermal cooling is the most important part of treating ethnic skin; however, too much cooling can result in postinflammatory hyperpigmentation.
  29. 29. Nonablative Lasers: Post-treatment care • Virtually all patients can return to work the same day.  There are no activity restrictions • Make-up may be applied immediately after treatment.  • Cooling gels can be used to minimize erythema and edema. • All patients should be counseled to use sunblock regularly to prevent repigmentation and postinflammatory hyperpigmentaton.  • There is no increased photosensitivity related to nonablative laser treatment.  
  30. 30. Conclusion (1) • With any ablative modality, treatment must be pursued cautiously and with specific precautions against scarring and pigmentary alteration. • Nonablative lasers are the result of technology meeting patient demands for “lunchtime” treatments. • Nonablative resurfacing is relatively new and, although results may be mild and sometimes inconsistent, new developments and protocols will improve efficacy.
  31. 31. • Although these devices do not produce the same degree of improvement as traditional CO or₂ Er:YAG resurfacing techniques, they are an excellent alternative for people seeking gradual aesthetic improvement with minimal downtime. • Non-ablative rejuvenation shows great potential in the treatment of darker skin types, who are prone to pigmentary alterations from classic resurfacing modalities, because of its emphasis on epidermal sparing. Conclusion (2)
  32. 32. Acknowledgments • Sonia Batra, MD, USC, LA, CA • Tina Bhutani, BSc, USC, LA,CA • Joy Kunishige, MD, UTHSC, Houston, TX • Paul Friedman, MD, UTHSC, Houston, TX Adapted from Cosmetic Dermatology (Elsevier 2009) Murad Alam, MD, Chicago, IL Hayes Gladstone, MD, Stanford, CA Rebecca Tung, MD, Cleveland, OH
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