Ablative & Nonablative Lasers for Face Rejuvenation
Ablative & NonablativeLasersfor Face Rejuvenation Dr. Christofer Tzermias Dermatologist Director Laser Dermatology Dept Athens Medical Center Greece
Introduction• 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 procedure is indicated.
Laser Rejuvenation• Laser light is monochromatic, coherent and collimated. Generates high fluence.• Reflected, Scattered, Transmitted, Absorbed• Absorbed energy – Thermal energy Clinical effect & collateral damage• 1956 – Maiman – Continuous output• 1985 – Selective Photothermolysis• Ultrashort pulses of high energy Ablate or do not ablate the epidermis Dermal wounding Thermal effect: significant or minimal
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 32000Nd:YAG 1064 0.0177 81100Nd:YAG 1320 0.204 7000Diode 1450 3.04 470Er.glass 1540 1.18 1200Er:YAG 2940 1220 1.20CO2 10600 84.40 17 μwater :absorption coefficient
Ablative LASER• Thecarbon dioxide laser has long been the “gold standard” for ablative resurfacing.•Results from traditional CO2 systems have beendramatic for severe photo-damage and scarring, butpatients need to be aware of associated downtimerequirements and the risk of pigmentation alterationin darker skin types.• Newer technologies, including erbium : yttrium-aluminum-garnet (Er: YAG) systems and fractionallasers, can treat a variety of cutaneous disorderswhile offering shorter recovery times and improvedsafety in a broader spectrum of skin types.
Preoperative patient checklistPerform complete patient medical historyand dermatologic examinationPatient education• Video demonstration• Review brochure• Show representative photographs• Provide information sheet• Take preoperative patient photographsBegin preoperative skin care regimenObtain informed consent for procedure
Preoperative patient evaluation (1/3) Does the patient have lesions that are amenable to laser resurfacing? Has previous treatment been received for the condition? Is the patient taking isotretinoin or immunosuppressive medication? What is the patient’s skin type? Does the patient have a history of cold sores?
Preoperative patient evaluation (2/3) Is there a history of collagen vascular disease or immunodeficiency? Are other dermatologic conditions present that could spread after treatment? Is the patient prone to acne breakouts? Does the patient have a tendency to form hypertrophic scars or keloids
Preoperative patient evaluation (3/3) Does the patient have realistic expectations of the procedure? Will the patient be compliant with all preoperative and postoperative instructions? Are there medical conditions that would interfere with using intravenous anesthesia?
Fitzpatrick skin typesSkin type Color Skin characteristics I. White Always burns, never tans II. White Usually burns, tans less than average III. White Sometimes mild burn, tans about average IV. White Rarely burns, tans more than average V. Brown Rarely burns, tans profusely VI. Black Never burns, deeply
Commonly used ablative modalitiesfor skin resurfacing:spectrum from least to most aggressive Least aggressive Microdermabrasion Superficial chemical peel Medium-depth chemical peel Deep chemical peel Fractional lasers Er: Yag laser CO2 lasers Most aggressive (greatest depth of ablation)
Glogau classification• The Glogau classification system helps the physician determine the deth of damage, and thus offers some indication of what the depth of resurfacing should be.• Patients with minimal photo-damage may require ablation of only the upper part of the epidermis.• Those with moderate photo-damage may require more extensive resurfacing to the level of the papillary dermis, and so on.
Glogau classification Damage I (mild)Description CharacteristicsNo wrinkles Early photo-aging: * Mild pigmentary changes * No keratoses * Minimal wrinkles * Patient age: 20s to 30s * Minimal or no make up * Minimal acne scarring
Glogau classification Damage II (moderate)Description Characteristicswrinkles in Early to moderate photo-motion aging: * Early senile lentigines * Keratoses palpable but not visible * Parallel smile lines beginning to appear * Patient age : 30s to 40s * Some foundation make-up worn * Mild acne scarring
Glogau classification Damage III.(advanced)Description Characteristicswrinkles at Advanced photo-aging:rest * Obvious dyschromias and telangiectasia * Visible keratoses * Static wrinkles present * Patient age : older than 50years * Heavy foundation usually worn * Acne scarring : make-up cannot cover
Glogau classification Damage IV.(severe)Description CharacteristicsOnly wrinkles Severe photo-aging: * Yellow-gray skin color * Prior skin malignancies * Wrinkles throughout- no normal skin * Patient age :60s or 70s * Make-up cannot be worn – it cakes and cracks * Severe acne scarring
Glogau classification• The patient’s goals and severity of condition will quide the therapeutic plan.• The potential improvement in texture afforded by this technique must be weighed against the greater potential for pigmentary alteration and/or scarring.
Carbon dioxide lasers (1/2)• CO2 laser resurfacing can be performed in the office or under anesthesia.• The wavelength 10,600nm.• Depth of tissue ablated per pass is approximately 20-30μm.• Thermal damage produced is 30-100 μm.• Time to re-epithelialization is 7-10days.• Duration of post-laser erythema is 3-6 months.• Significant collagen shrinkage and remodeling requires at least two passes.• A greater number of passes or excess energy densities results in an increased risk of scarring.• CO2 systems in pulsed or scanning modes deliver predictable ablation levels and consistent results.
Carbon dioxide lasers (2/2)• Advantages include excellent tissue contractions and hemostasis.• Valuable for treating entire cosmetic subunits, focal lesions, or full-face resurfacing.• Indications include moderate to severe rhytides and photo-damage, scarring, actinic keratosis, and other superficial lesions.• In darker skin types, more conservative settings and fewer passes can decrease the risk of scarring and pigment alteration.• Laser “test spots” in inconspicuous areas can be performed in patients at high risk of dyschromia.
Preoperative care for CO2 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, soy, azelaic acid, and others can also be used to reduce postinflammatory hyperpigmentation. Anxious patients: oral benzodiazepines such as diazepam (5-10 mg) can be given half an hour before the procedure.
Postoperative care for CO2 laser useWound care:dilute acetic acid, saline, or tap water soaksevery 2-4 h followed by bland emollientsare essential for proper healingMedications :continuation of oral antibiotics and antiviral drugs;short-term pain medications including narcoticsshould be given in necessaryFollow-up:post-laser follow-up in the office at 2-5 days isvaluable to note the quality of the patient’swound care and the progress of wound healing.
Erbium : yttrium-aluminum-garnet laser • Can be performed in the office or under anesthesia. • Wavelength 2940 nm. • Tissue ablated per pass approximately 2-3 μm. • Thermal damage produced 5-30 μm. • Time to re-epithelialization 4-5 days. • Duration of post-laser erythema 3-4 weeks. • Er: YAG produces less thermal damage than the CO2 laser-multiple passes are needed to ablate to an equivalent level. • Indicatiοns are mild to moderate rhytides and photo-damage, mild to moderate scarring, and superficial lesions. • Can be a good option in patients with darker skin types.
Side –effects and complications of ablative laser skin resurfacingSide-effects Mild complicationsTransient erythema Prolonged erythemaLocalized edema MiliaPruritus Acne Contact dermatitis
Side –effects and complicationsof ablative laser skin resurfacingModerate Severecomplications complicationsPigmentary change Hypertrophic scarInfections Ectropion(bacterial,fungal,viral)
Management of adverse events Hyperpigmentation:Continue broad-spectrum sun protection, bleaching creams, and series or superficial peels Infection:Be guided by culture and sensitivity Scarring:Aggressive treatment will lead to resolution.Topical steroid creams with intralesional steroidsif hypertrophic scars, series of pulsed dye lasertreatments, silicone sheeting, or topical gels.Arrange frequent gratis follow-up visits in your office
Fractional ablative lasers• Fractional laser devices produce rejuvenation and collagen remodeling by creating thousands of microscopic wounds called microscopic treatment zones (MTZs) with sparing of adjacent skin.• Indications include mild to moderate rhytides and photo-damage, acne scars, pigmented lesions, and actinic keratoses.
Fractional laser treatment allows toobtain remarkable results withminimal downtime.The laser energy, applied in a fractional way,creates very thin and spaced columns of thermaldamage which penetrate deep into the dermalskin layer and stimulate a new collagenproduction. The tissuebetween the columnsof thermal damage isspared, resulting ina faster healing process.
Fractionated lasersFractional delivery may be superior to traditional uniform delivery of heat for three reasons:• Higher irradiation within the columns results in more damage and increased wound healing response. This can be achieved without increasing the power of the optical source.• Faster healing response due to increased surface-to- volume ratio of the microwounds. The interface between injured and normal skin, where most neocollagen formation occures, is maximized.• Larger safety margin as fractional resurfacing is less likely to result in infections and scarring.
Various CO2 lasers with fractionedemission are currently available on themarket. Despite the fact that all these systems are based on the same principles, they present significant differences with regard to output power, dwell-time, distance between the dots, varying scanner shapes and the laser beam profile. These differences may produce clinical results that differ greatly between one device and another.
Considerations in darker skinNonablative technologies are considered first-line because of a lower risk of postoperative complications.However, ablative therapies (combination treatment with CO2 and erbium lasers, single-pass CO2 laser, or long-pulsed Er :YAG systems) can be used in a conservative fashion to treat advanced damage and scarring.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 Lasers• Nonablative lasers heat the papillary and reticular dermis, without damaging the epidermis, to stimulate collagen synthesis.• Synonyms include nonablative remodeling.• Applications include photo-aging, acne, and acne scars.• Compared with ablative procedures, nonablative resurfacing provides more modest improvements, but with essentially no downtime and an excellent safety profile.
Index of nonablative devices available • Pulsed-dye lasers (PDLs) were the first modality to be used for nonablative remodeling and show to improve acne vulgaris. • Neodymium: yttrium-aluminum-garnet (Nd:YAG) lasers benefit rhytides and acne scarring. • 1450-nm diode is effective for rhytides, acne, and acne scarring, but is associated with some pain. • 1540-nm erbium: glass may be used for rhytides or acne. • Fractionated erbium lasers are nonablative with a growing list of applications.
Fractionated nonablative lasers• Synonym: fractional photothermolysis• Fractionated lasers deliver energy to vertical columns of skin to create microscopic treatment zones (MTZs)• Inter-MTZ skin remains untreated and serves as a reservoir of healthy skin to speed healing• Multiple passes and treatment sessions are needed to treat a given area completely• Results are probably somewhere between that of nonablative and ablative laser therapy, although efficacy differs widely from patient to patient
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
Pretreatment checklistNumber of treatments that will be requiredAmount of improvement to expect-show realistic before and after picturesAvoid certain medications for 1 week before and after certain laser procedures:• Aspirin• Ibuprofen• Vitamin E• Anti-inflammatory medications• Photosensitizing medications
Pretreatment checklistStop topical medications for 2 days before and after:• tretinoin topical• a-hydroxy acids• vitamin C derivativesConfirm no contraindications for laser treatment:• pregnancy• history of keloids• current suntan• isotretinoin therapy within 6 months• lupus erythematosus or other photosensitivity
Pretreatment checklistIf history of herpes simplex virus,prescribe valaciclovir 500mg by mouth twice daily for 3 days. Start 1 day before procedureIf petreatment anesthesia needed, prescribe topical anesthetic such as EMLA cream to treatment area 1 h before treatment under plastic wrap occlusion.Pretreatment photos in a reproducible position and lightingEye protection for patient and physicianTeeth protection for patient
Selected nonablative light sources and suggested parameters (3/8)Laser Wavelength(nm) Indications ParametersNd:YAG 1064 photo-damage; Energy(CoolTouch II; acne scarring 12-16 j/cm2,ICN DCDPharmaceuticals) before during and after
Selected nonablative light sources and suggested parameters (4/8)Laser Wavelength(nm) Indications ParametersDiode(Smooth 1450 Photo-damage 12-14 J/cm2Beam, ICN acne and acne 6mm spotPhotonics) scarring DCD before, during and after
Selected nonablative light sources and suggested parameters (5/8)Laser Wavelength(nm) Indications ParametersEr:glass 1,540 Photo-damage 3 pulses(Aramis per shot,-Quantel 10J per pulseLaser; Quantel fluenceMedical, 30J/cm2, 4-mm spot, slightlyFrance) ovelrapping pulses, no visible changes occur
Selected nonablative light sources and suggested parameters (6/8)Laser Wavelenght(nm) Indications ParametersFractional 1500 Photo-damage Treatmentlaser (Fraxel acne and acne level 8-11re:store Reliant scarring to obtain23-32%Technologies) coverage, energy level 50-70mJ, approximately 8 passes to deliver total of 3-4kJ
Selected nonablative light sources and suggested parameters (7/8)Laser Wavelength(nm) Indications ParametersIntense 500-1200 Photo-damage, 560nmPulsed light including filter,fluence(Lumenis One, poikiloderma 16-18J/cm2 Lumenis of Civatte;acne with thinSanta Clara,CA) layer of gel. Double pulse with3- 4ms pulse duration and delay of 10ms. Parameters may vary for other systems
Selected nonablative light sources and suggested parameters (8/8)Laser Wavelenght(nm) Indications ParametersLED Preodominantly Periorbital Total output(Gentle 590 thytides of 0.1 j/cm2Waves, per treatmentVirginia has beenBeach, reportedVA)
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
Adverse events associated with nonablative lasers (1/3)Adverse event CommentsPain Depends on device, more so with deep- infrared devices that target waterErythema Usually clears in hours, but can last several days. This is expected endpoint with Fraxel re: storeEdema Usually clears within 24h. May last longer with Fraxel re: store
Adverse events associated with nonablative lasers (2/3)Adverse event CommentsPurpura Most Commonly occurs with PDL. Transient purpura may be obtained when treating telangiestacia. For acne and photo-aging lower fluence or lengthen pulse durationCrusting Indicates too much epidermal heatingBlistering Indicates too much epidermal heating: may result in scarring
Adverse events associated with nonablative lasers (3/3)Adverse event CommentsInfection Query patient as to history of prior HSV infection. Consider Staphylococcus aureus infection if epidermis is inadvertently ablatedDyspigmentation Most common in darker skin types. Correct amount of epidermal cooling should be used.Textural scarring Rare
ConclusionWith 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 “Iunchtime” treatments. Nonablative resurfacing is relatively new and, although results may be mild and sometimes inconsistent, new developments and protocols will improve efficacy, with an outstanding safety profile.