Tissue Tightening: Where We Are with This Technology
Kenneth A. Arndt, M.D.
Tissue tightening” is a term often used by physicians and the public, and it is the subject of seminars, scientific presentations, intense marketing and the focus of numerous Web sites. A quick Google search I conducted yielded more than 1.3 million sites for the term “tissue tightening”.
It’s no secret that many instruments, wavelengths, and strategies are now available that are aimed at bringing about this sought-after change in the structure of the skin and its appearance.
Decade of Grappling with Terminology
The first technology for tissue tightening appeared less than 10 years ago, and because it is still such an evolving and difficult-to-quantitate area, the FDA has not accepted any means of assessing skin tightening — and it is not an FDA-approved procedure. Although there are many devices now available that nicely induce this clinical result, no marketing from any of these manufacturers ever mentions the term “tissue tightening”.
The prospect of being able to “tighten” skin and thus bring about diminution in lines and wrinkles with a non-invasive procedure is very seductive. Devices have generally been approved for diminution of the appearance of wrinkles, or for heating the skin, or for improving the tone and texture of the skin and improving tissue laxity.
The means by which non-invasive tissue tightening comes about is through heating the skin without damaging or removing the overlying epidermis. The heat induces both mechanical and biochemical effects that produce a tightening effect and a wound healing response with neocollagenesis. Because it is paramount that the outer aspects of skin be protected, most technologies incorporate a cooling mechanism so that heat may be deposited deeply while the epidermis remains cool and unaffected.
What’s Available
The ThermaCool device from Thermage was the first device approved in this category 8 years ago. This treatment is based on a monopolar radiofrequency system that produces volumetric heating of broad areas within the dermis as well as into the septae of the subcutaneous tissue. When this originally came on the market, it was thought that one or two passes at high intensities were the optimal treatment regimen.
Over time, this has been modified so that it is both more effective, less uncomfortable, and unlikely to bring about any side effects, with the use of low-intensity multiple-pass treatments.
The Polaris (Syneron) is a diode laser (780 nm to 980 nm) with bipolar radiofrequency using both light and radiofrequency (RF) energy to heat the dermis. Light and RF are thought to work synergistically, while cooling is found within the treatment tip. The primary indication for this technology has been for reduction of wrinkles.
More recently, Syneron has released the ReFirme, which combines infrared light (700 nm to 2000 nm) and bipolar radiofrequency.
Bipolar radiofrequency combined with a vacuum is the basis for the Aluma (Lumenis), which is FDA approved for the treatment of fine lines and wrinkles. As the skin is drawn up between two electrodes, skin between these electrodes may be able to be treated with lower energy levels, greater depth of penetration, increased safety and less pain.
The Titan (Cutera) emits light in 1100-nm to 1800-nm wavelength range through a cool window that is held in contact with skin. Some cutaneous contraction has been noted for up to 12 months post-treatment.
Fractional infrared energy is delivered through the infrared (IR) head of the StarLux IR (Palomar), which emits light from 850 nm to 1350 nm through a cold contact head. Several treatments are necessary to bring about remodeling of collagen.
Energy from 1064-nm lasers reach great depths within the dermis and this wavelength has been used in an attempt to bring about tissue tightening. The long-pulsed millisecond Nd:YAG laser has been shown to be effective in improving skin laxity in at least one study with improvement lasting for up to 6 months.
Common Threads of Tissue Tightening
All of the tissue tightening treatments involve heating the skin and thus are accompanied by varying degrees of discomfort. If the skin is heated over a certain threshold, or if the cooling mechanism is not appropriate or fails, cutaneous injury in the form of burns or pigmentary changes or contour changes may be seen. However, this is quite uncommon.
With many of these devices, it is possible to appreciate the appearance of immediate tissue tightening and contraction if only one side of the face is initially treated. Subsequent changes within skin brought about by thermal dermal injury continue to evolve over the next 6 months or more.
No controlled clinical studies exist that have compared one device with another and it is not possible to rank devices in order of efficacy. Indeed, it is often difficult to demonstrate efficacy, even when it is there, for there are no good methods to demonstrate quantitative tissue tightening. Three-dimensional imaging may be the best way to show these often-subtle changes. Although biochemical, histologic and electromicroscopic changes have been found after various tissue tightening treatments, the correlation between these findings and clinical efficacy is sometimes difficult to make.
Still on the Learning Curve
This technology is less than a decade old, and the clinical results are variable. Reliable, effective, reproducible, non-painful, non-invasive tissue tightening will be a valuable method of great utility to many patients. With further knowledge about proper usage and subsequent clinical and laboratory studies, we may be able to better understand this very interesting area and provide more realistic expectations.
Laser/Light Skin Resurfacing: What’s Next?
Jeffrey S. Dover, M.D., FRCPC
Ever since the early 1990s when CO2 laser resurfacing was developed, the search has been on for a technology that will equal the dramatic improvements in photoaging and acne scarring produced by CO2 resurfacing but without the significant side effects associated with it.
Non-ablative skin rejuvenation was created as the alternative to the frequent and significant complications experienced with CO2 laser skin resurfacing. Yet, although the mid-infrared devices at 1320 nm, 1440 nm and 1540 nm improved skin texture, improved acne scars somewhat better, and resulted in very well tolerated procedures that rarely had side effects — in general, the results of these treatments have been disappointing.
Newer Technologies for Resurfacing: The Answer?
Over the last few years, a variety of new ablative, and coagulative non-ablative laser-, light-, and energy-based technologies have been developed in an effort to achieve effective improvement of photoaging and acne scarring with an acceptable safety profile. These devices include variable pulse 2940-nm erbium:YAG laser resurfacing, 1540-nm and 1420-nm fractional erbium:YAG laser resurfacing, fractional 10,600-nm CO2 laser resurfacing and plasma skin rejuvenation.
Variable-pulsed erbium:YAG laser resurfacing. With this technology, the amount of energy can be dialed in to ablate predictable amounts of the epidermis and dermis. Termed the “micro laser peel”, the more energy delivered to the skin, the greater the wound, the longer the downtime, and the greater the degree of improvement.
Fractional resurfacing affects columns of skin, up to 100µ in diameter, which are thermally damaged, leaving completely unaltered areas of skin between the treated columns. The term “fractional” is used because only a fraction of the treated area is affected with each treatment. Redness and swelling after each procedure lasts an average of 3 days, depending on the device used. A series of five to six treatments is usually needed to achieve optimal improvement of sun-induced dyspigmentation, wrinkle reduction, or acne scarring.
Fractional CO2 laser resurfacing builds on the technical advances of fractional Er:YAG resurfacing. A scanner deposits an array of 120-micron diameter beams of CO2 laser energy. This energy vaporizes tiny columns of tissue. The result is not only improved color and texture but also skin tightening. Early studies predict that significant results will be attained with one or two treatments. The healing phase is a bit longer than with fractional erbium laser resurfacing — patients experience hemorrhage, crusting, swelling, and redness that lasts an average of about 1 week, depending on the treatment parameters.
In plasma skin rejuvenation, plasma, the fourth state of energy, generates heat in the epidermis and dermis, which results in coagulation that occurs in a graduated fashion to induce improvement to the skin. The degree of improvement to the skin is determined by the energy delivered and the number of passes. The procedure can be performed across a spectrum. At one end, the procedure can be done so gently that there is absolutely no discomfort and no post-operative downtime — but with limited improvement. At the other end of the spectrum, treatment is more painful and complete epidermal regeneration occurs with 10 days of downtime and quite dramatic improvements in both the color and texture of the skin.
Exploring the Potential of These Newer Treatments
Each of these procedures has the potential for:
• improving sun-induced skin color
• improving skin texture
• producing mild to modest skin tightening
• improving acne scarring.
Unlike traditional CO2 laser skin resurfacing, however, each procedure induces less oozing, less crusting, less scabbing, less erythema, a shorter healing time, and a much lower risk of side effects. None of these procedures has yet been reported to induce long-term hypopigmentation. In addition, while there may have been cases of infection or scarring, they have yet to be reported in the literature.
These procedures are easier for physicians to learn to perform, and far less painful and risky than CO2 laser skin resurfacing. So what is the trade-off? While we are getting closer, thus far, none of these alternative procedures have produced the kind of wrinkle reduction and skin tightening seen with traditional CO2 laser skin resurfacing.
The Choice Is Clear
Given our desire for safety combined with efficacy, most of us and our patients would prefer one of these less-involved, less-effective procedures to avoid the potential complications of CO2 laser skin resurfacing.
Adjunct Treatment for Recalcitrant Acne
Girish Munavalli, M.D., and Robert Weiss, M.D.
Photopneumatic therapy (PPx) using Aesthera’s second-generation device, Isolaz, has proven effective for our patients in a recent clinical trial we conducted in patients who have recalcitrant acne.
The device works by utilizing pulsed light concurrently with vacuum pressure. The proposed mechanisms of action for treating patients who have comedonal, nodulocystic and papulo-pustular facial acne are as follows:
1. works to treat acne by reducing sebaceous load and follicular plugging
2. uses pulsed light to selectively heat dermal structures, rapidly reducing pilosebaceous inflammation
3. activates Propionibacterium acnes porphyrins.
Recent Study Results with This Device
In a study of 15 patients who had recalcitrant acne, especially those with inflammatory papules, pustules and comedones, we conducted a series of four treatments with Isolaz. These patients had been undergoing treatment with topicals and antibiotics, and we introduced the concept of Isolaz to these patients right away to jumpstart their treatment. We did not focus on patients who hadn’t undergone conventional acne treatments.
During treatment with Isolaz, we made three to five passes with the device, which took about 20 minutes total. Patients underwent four treatments — one a week for four weeks — and then were evaluated 1 month post-treatment. (See photo above to view one of our patients who was treated.) No topical anesthesia was needed prior to the treatments, and afterward, patients experienced only mild transient redness along with a less than 5% incidence of purpura. There was no downtime with this procedure.
Some patients experienced dramatic improvement in their acne within one to two treatments, and all patients experienced at least moderate improvement within the first two treatments. One to 2 months following treatment, patients reported less skin oiliness and a decreased number of new acne lesions. Even female patients with hormone-sensitive acne reported less acne flaring along in conjunction with their menstrual cycles. So there is definitely some prolonged benefit after treatment ends.
We’re always trying to get patients to the maintenance phase of their acne treatment, and this treatment was beneficial. Overall, all of the patients seemed to get improvement to some degree, and patients have overall been satisfied with this treatment. n
Treating Port Wine Stains and Other Vascular Lesions
Elizabeth Tanzi, M.D.
For patients who have recalcitrant and hypertrophic port wine stains and other vascular lesions, a new technology that delivers a kind of “one-two punch” has demonstrated advantages over what is currently available. The Cynergy laser (Cynosure) with the MultiPlex feature delivers timed, sequential pulses of a 595-nm pulsed dye laser followed by 1064-nm Nd:YAG.
The initial absorption of the pulsed dye laser wavelength causes heating and subsequent conversion of oxyhemoglobin to methemoglobin. Methemoglobin is 3 to 5 times better able to absorb energy from the Nd:YAG laser at 1064 nm. With the two wavelengths — one followed immediately after the other — the MultiPlex feature allows deeper heating of the vessels, which is particularly helpful for hypertrophic port wine stains. This technology has been a great advance in my practice.
In a clinical study, Dr. Tina Alster and I treated 25 children and adults who had recalcitrant port wine stains (defined as minimal improvement after 10 or more pulsed dye laser treatments) with the Cynergy laser using the MultiPlex feature. Patients were treated at 6-week intervals using a 10-mm spot size and energies of 7.0 to 9.0 J/cm2 for the 595-nm PDL and 25 to 45 J/cm2 with the 1064-nm Nd: YAG. Pulse durations were 6 or 10 ms with the 595-nm wavelength and 1 ms with the Nd:YAG, with a delay of 0.5 to 1 second between pulses. Concomitant air cooling provided epidermal protection.
All of the patients in our study showed improvement of varying degrees. The majority of patients experienced edema and mild purpura; however, no patients exhibited vesicle formation, dyspigmentation or scarring.
Currently in my practice, the vast majority of my patients with telangiectasias, rosacea or port wine stains are receiving treatment with this device. (See photo.) I’ve found that this technology is more effective in treating these conditions than the pulsed dye laser alone and provides good clinical improvement with fewer treatment visits. n
A New Twist on Erbium Resurfacing
Amy Forman Taub, M.D.
The yttrium scandium gallium garnet (YSGG) provides a new twist on erbium resurfacing. Its different wavelength (2790 nm vs. 2940 nm) enables it to deliver efficient ablation and some coagulation, resulting in minimal post-operative oozing and no need for occlusive dressings.
Because of the reduced post-operative morbidity and consistent results, the YSGG has been a patient-pleasing addition to our armamentarium for the subset of patients who want fast results for both mild wrinkling and photodamage and are willing to put up with a short period of downtime.
Dubbed the Pearl by Cutera, Inc, this laser utilizes a wavelength that is off the peak of water absorption. The advantage of this is that it still ablates very effectively, but also delivers some coagulation. This translates into vaporization of the epidermis and a mild heating of the upper dermis, potentially yielding more collagen induction than with traditional erbium alone. With this procedure, a layer of coagulated epidermis remains intact after treatment, serving as a “natural dressing” that hinders oozing and bleeding and eliminates the need for hydrocolloid dressings post-operatively.
Downtime is limited to 3 to 4 days with minimal discomfort and no need for complex skin care. By day 4 make up will conceal the fact that a procedure was done, although some peeling usually occurs for 5 to 10 days. Within 1 to 2 weeks, the skin is completely healed and with it enough of an improvement that the patients’ friends and family members notice the positive change.
There is no prolonged post-operative erythema or hypo- or hyper-pigmentation as long as a single-pass protocol is observed.
The Pearl isn’t for deep rhytides or anything but the most superficial acne scars. But for that niche of patients who want to be refreshed, don’t want multiple treatments, have mild rhytides, mild-to-moderate solar elastosis and are willing to experience a short downtime, this technology offers a great choice.
This twist on an older technology (superficial erbium resurfacing), which was unpalatable to most of our patients, has led to less downtime and pain, no dressings and low risk. By using the proper parameters and no more than one pass, this effective and safe new erbium treatment has become a commonly performed and popular procedure in our office.
Tissue Tightening: Where We Are with This Technology
Kenneth A. Arndt, M.D.
Tissue tightening” is a term often used by physicians and the public, and it is the subject of seminars, scientific presentations, intense marketing and the focus of numerous Web sites. A quick Google search I conducted yielded more than 1.3 million sites for the term “tissue tightening”.
It’s no secret that many instruments, wavelengths, and strategies are now available that are aimed at bringing about this sought-after change in the structure of the skin and its appearance.
Decade of Grappling with Terminology
The first technology for tissue tightening appeared less than 10 years ago, and because it is still such an evolving and difficult-to-quantitate area, the FDA has not accepted any means of assessing skin tightening — and it is not an FDA-approved procedure. Although there are many devices now available that nicely induce this clinical result, no marketing from any of these manufacturers ever mentions the term “tissue tightening”.
The prospect of being able to “tighten” skin and thus bring about diminution in lines and wrinkles with a non-invasive procedure is very seductive. Devices have generally been approved for diminution of the appearance of wrinkles, or for heating the skin, or for improving the tone and texture of the skin and improving tissue laxity.
The means by which non-invasive tissue tightening comes about is through heating the skin without damaging or removing the overlying epidermis. The heat induces both mechanical and biochemical effects that produce a tightening effect and a wound healing response with neocollagenesis. Because it is paramount that the outer aspects of skin be protected, most technologies incorporate a cooling mechanism so that heat may be deposited deeply while the epidermis remains cool and unaffected.
What’s Available
The ThermaCool device from Thermage was the first device approved in this category 8 years ago. This treatment is based on a monopolar radiofrequency system that produces volumetric heating of broad areas within the dermis as well as into the septae of the subcutaneous tissue. When this originally came on the market, it was thought that one or two passes at high intensities were the optimal treatment regimen.
Over time, this has been modified so that it is both more effective, less uncomfortable, and unlikely to bring about any side effects, with the use of low-intensity multiple-pass treatments.
The Polaris (Syneron) is a diode laser (780 nm to 980 nm) with bipolar radiofrequency using both light and radiofrequency (RF) energy to heat the dermis. Light and RF are thought to work synergistically, while cooling is found within the treatment tip. The primary indication for this technology has been for reduction of wrinkles.
More recently, Syneron has released the ReFirme, which combines infrared light (700 nm to 2000 nm) and bipolar radiofrequency.
Bipolar radiofrequency combined with a vacuum is the basis for the Aluma (Lumenis), which is FDA approved for the treatment of fine lines and wrinkles. As the skin is drawn up between two electrodes, skin between these electrodes may be able to be treated with lower energy levels, greater depth of penetration, increased safety and less pain.
The Titan (Cutera) emits light in 1100-nm to 1800-nm wavelength range through a cool window that is held in contact with skin. Some cutaneous contraction has been noted for up to 12 months post-treatment.
Fractional infrared energy is delivered through the infrared (IR) head of the StarLux IR (Palomar), which emits light from 850 nm to 1350 nm through a cold contact head. Several treatments are necessary to bring about remodeling of collagen.
Energy from 1064-nm lasers reach great depths within the dermis and this wavelength has been used in an attempt to bring about tissue tightening. The long-pulsed millisecond Nd:YAG laser has been shown to be effective in improving skin laxity in at least one study with improvement lasting for up to 6 months.
Common Threads of Tissue Tightening
All of the tissue tightening treatments involve heating the skin and thus are accompanied by varying degrees of discomfort. If the skin is heated over a certain threshold, or if the cooling mechanism is not appropriate or fails, cutaneous injury in the form of burns or pigmentary changes or contour changes may be seen. However, this is quite uncommon.
With many of these devices, it is possible to appreciate the appearance of immediate tissue tightening and contraction if only one side of the face is initially treated. Subsequent changes within skin brought about by thermal dermal injury continue to evolve over the next 6 months or more.
No controlled clinical studies exist that have compared one device with another and it is not possible to rank devices in order of efficacy. Indeed, it is often difficult to demonstrate efficacy, even when it is there, for there are no good methods to demonstrate quantitative tissue tightening. Three-dimensional imaging may be the best way to show these often-subtle changes. Although biochemical, histologic and electromicroscopic changes have been found after various tissue tightening treatments, the correlation between these findings and clinical efficacy is sometimes difficult to make.
Still on the Learning Curve
This technology is less than a decade old, and the clinical results are variable. Reliable, effective, reproducible, non-painful, non-invasive tissue tightening will be a valuable method of great utility to many patients. With further knowledge about proper usage and subsequent clinical and laboratory studies, we may be able to better understand this very interesting area and provide more realistic expectations.
Laser/Light Skin Resurfacing: What’s Next?
Jeffrey S. Dover, M.D., FRCPC
Ever since the early 1990s when CO2 laser resurfacing was developed, the search has been on for a technology that will equal the dramatic improvements in photoaging and acne scarring produced by CO2 resurfacing but without the significant side effects associated with it.
Non-ablative skin rejuvenation was created as the alternative to the frequent and significant complications experienced with CO2 laser skin resurfacing. Yet, although the mid-infrared devices at 1320 nm, 1440 nm and 1540 nm improved skin texture, improved acne scars somewhat better, and resulted in very well tolerated procedures that rarely had side effects — in general, the results of these treatments have been disappointing.
Newer Technologies for Resurfacing: The Answer?
Over the last few years, a variety of new ablative, and coagulative non-ablative laser-, light-, and energy-based technologies have been developed in an effort to achieve effective improvement of photoaging and acne scarring with an acceptable safety profile. These devices include variable pulse 2940-nm erbium:YAG laser resurfacing, 1540-nm and 1420-nm fractional erbium:YAG laser resurfacing, fractional 10,600-nm CO2 laser resurfacing and plasma skin rejuvenation.
Variable-pulsed erbium:YAG laser resurfacing. With this technology, the amount of energy can be dialed in to ablate predictable amounts of the epidermis and dermis. Termed the “micro laser peel”, the more energy delivered to the skin, the greater the wound, the longer the downtime, and the greater the degree of improvement.
Fractional resurfacing affects columns of skin, up to 100µ in diameter, which are thermally damaged, leaving completely unaltered areas of skin between the treated columns. The term “fractional” is used because only a fraction of the treated area is affected with each treatment. Redness and swelling after each procedure lasts an average of 3 days, depending on the device used. A series of five to six treatments is usually needed to achieve optimal improvement of sun-induced dyspigmentation, wrinkle reduction, or acne scarring.
Fractional CO2 laser resurfacing builds on the technical advances of fractional Er:YAG resurfacing. A scanner deposits an array of 120-micron diameter beams of CO2 laser energy. This energy vaporizes tiny columns of tissue. The result is not only improved color and texture but also skin tightening. Early studies predict that significant results will be attained with one or two treatments. The healing phase is a bit longer than with fractional erbium laser resurfacing — patients experience hemorrhage, crusting, swelling, and redness that lasts an average of about 1 week, depending on the treatment parameters.
In plasma skin rejuvenation, plasma, the fourth state of energy, generates heat in the epidermis and dermis, which results in coagulation that occurs in a graduated fashion to induce improvement to the skin. The degree of improvement to the skin is determined by the energy delivered and the number of passes. The procedure can be performed across a spectrum. At one end, the procedure can be done so gently that there is absolutely no discomfort and no post-operative downtime — but with limited improvement. At the other end of the spectrum, treatment is more painful and complete epidermal regeneration occurs with 10 days of downtime and quite dramatic improvements in both the color and texture of the skin.
Exploring the Potential of These Newer Treatments
Each of these procedures has the potential for:
• improving sun-induced skin color
• improving skin texture
• producing mild to modest skin tightening
• improving acne scarring.
Unlike traditional CO2 laser skin resurfacing, however, each procedure induces less oozing, less crusting, less scabbing, less erythema, a shorter healing time, and a much lower risk of side effects. None of these procedures has yet been reported to induce long-term hypopigmentation. In addition, while there may have been cases of infection or scarring, they have yet to be reported in the literature.
These procedures are easier for physicians to learn to perform, and far less painful and risky than CO2 laser skin resurfacing. So what is the trade-off? While we are getting closer, thus far, none of these alternative procedures have produced the kind of wrinkle reduction and skin tightening seen with traditional CO2 laser skin resurfacing.
The Choice Is Clear
Given our desire for safety combined with efficacy, most of us and our patients would prefer one of these less-involved, less-effective procedures to avoid the potential complications of CO2 laser skin resurfacing.
Adjunct Treatment for Recalcitrant Acne
Girish Munavalli, M.D., and Robert Weiss, M.D.
Photopneumatic therapy (PPx) using Aesthera’s second-generation device, Isolaz, has proven effective for our patients in a recent clinical trial we conducted in patients who have recalcitrant acne.
The device works by utilizing pulsed light concurrently with vacuum pressure. The proposed mechanisms of action for treating patients who have comedonal, nodulocystic and papulo-pustular facial acne are as follows:
1. works to treat acne by reducing sebaceous load and follicular plugging
2. uses pulsed light to selectively heat dermal structures, rapidly reducing pilosebaceous inflammation
3. activates Propionibacterium acnes porphyrins.
Recent Study Results with This Device
In a study of 15 patients who had recalcitrant acne, especially those with inflammatory papules, pustules and comedones, we conducted a series of four treatments with Isolaz. These patients had been undergoing treatment with topicals and antibiotics, and we introduced the concept of Isolaz to these patients right away to jumpstart their treatment. We did not focus on patients who hadn’t undergone conventional acne treatments.
During treatment with Isolaz, we made three to five passes with the device, which took about 20 minutes total. Patients underwent four treatments — one a week for four weeks — and then were evaluated 1 month post-treatment. (See photo above to view one of our patients who was treated.) No topical anesthesia was needed prior to the treatments, and afterward, patients experienced only mild transient redness along with a less than 5% incidence of purpura. There was no downtime with this procedure.
Some patients experienced dramatic improvement in their acne within one to two treatments, and all patients experienced at least moderate improvement within the first two treatments. One to 2 months following treatment, patients reported less skin oiliness and a decreased number of new acne lesions. Even female patients with hormone-sensitive acne reported less acne flaring along in conjunction with their menstrual cycles. So there is definitely some prolonged benefit after treatment ends.
We’re always trying to get patients to the maintenance phase of their acne treatment, and this treatment was beneficial. Overall, all of the patients seemed to get improvement to some degree, and patients have overall been satisfied with this treatment. n
Treating Port Wine Stains and Other Vascular Lesions
Elizabeth Tanzi, M.D.
For patients who have recalcitrant and hypertrophic port wine stains and other vascular lesions, a new technology that delivers a kind of “one-two punch” has demonstrated advantages over what is currently available. The Cynergy laser (Cynosure) with the MultiPlex feature delivers timed, sequential pulses of a 595-nm pulsed dye laser followed by 1064-nm Nd:YAG.
The initial absorption of the pulsed dye laser wavelength causes heating and subsequent conversion of oxyhemoglobin to methemoglobin. Methemoglobin is 3 to 5 times better able to absorb energy from the Nd:YAG laser at 1064 nm. With the two wavelengths — one followed immediately after the other — the MultiPlex feature allows deeper heating of the vessels, which is particularly helpful for hypertrophic port wine stains. This technology has been a great advance in my practice.
In a clinical study, Dr. Tina Alster and I treated 25 children and adults who had recalcitrant port wine stains (defined as minimal improvement after 10 or more pulsed dye laser treatments) with the Cynergy laser using the MultiPlex feature. Patients were treated at 6-week intervals using a 10-mm spot size and energies of 7.0 to 9.0 J/cm2 for the 595-nm PDL and 25 to 45 J/cm2 with the 1064-nm Nd: YAG. Pulse durations were 6 or 10 ms with the 595-nm wavelength and 1 ms with the Nd:YAG, with a delay of 0.5 to 1 second between pulses. Concomitant air cooling provided epidermal protection.
All of the patients in our study showed improvement of varying degrees. The majority of patients experienced edema and mild purpura; however, no patients exhibited vesicle formation, dyspigmentation or scarring.
Currently in my practice, the vast majority of my patients with telangiectasias, rosacea or port wine stains are receiving treatment with this device. (See photo.) I’ve found that this technology is more effective in treating these conditions than the pulsed dye laser alone and provides good clinical improvement with fewer treatment visits. n
A New Twist on Erbium Resurfacing
Amy Forman Taub, M.D.
The yttrium scandium gallium garnet (YSGG) provides a new twist on erbium resurfacing. Its different wavelength (2790 nm vs. 2940 nm) enables it to deliver efficient ablation and some coagulation, resulting in minimal post-operative oozing and no need for occlusive dressings.
Because of the reduced post-operative morbidity and consistent results, the YSGG has been a patient-pleasing addition to our armamentarium for the subset of patients who want fast results for both mild wrinkling and photodamage and are willing to put up with a short period of downtime.
Dubbed the Pearl by Cutera, Inc, this laser utilizes a wavelength that is off the peak of water absorption. The advantage of this is that it still ablates very effectively, but also delivers some coagulation. This translates into vaporization of the epidermis and a mild heating of the upper dermis, potentially yielding more collagen induction than with traditional erbium alone. With this procedure, a layer of coagulated epidermis remains intact after treatment, serving as a “natural dressing” that hinders oozing and bleeding and eliminates the need for hydrocolloid dressings post-operatively.
Downtime is limited to 3 to 4 days with minimal discomfort and no need for complex skin care. By day 4 make up will conceal the fact that a procedure was done, although some peeling usually occurs for 5 to 10 days. Within 1 to 2 weeks, the skin is completely healed and with it enough of an improvement that the patients’ friends and family members notice the positive change.
There is no prolonged post-operative erythema or hypo- or hyper-pigmentation as long as a single-pass protocol is observed.
The Pearl isn’t for deep rhytides or anything but the most superficial acne scars. But for that niche of patients who want to be refreshed, don’t want multiple treatments, have mild rhytides, mild-to-moderate solar elastosis and are willing to experience a short downtime, this technology offers a great choice.
This twist on an older technology (superficial erbium resurfacing), which was unpalatable to most of our patients, has led to less downtime and pain, no dressings and low risk. By using the proper parameters and no more than one pass, this effective and safe new erbium treatment has become a commonly performed and popular procedure in our office.
Tissue Tightening: Where We Are with This Technology
Kenneth A. Arndt, M.D.
Tissue tightening” is a term often used by physicians and the public, and it is the subject of seminars, scientific presentations, intense marketing and the focus of numerous Web sites. A quick Google search I conducted yielded more than 1.3 million sites for the term “tissue tightening”.
It’s no secret that many instruments, wavelengths, and strategies are now available that are aimed at bringing about this sought-after change in the structure of the skin and its appearance.
Decade of Grappling with Terminology
The first technology for tissue tightening appeared less than 10 years ago, and because it is still such an evolving and difficult-to-quantitate area, the FDA has not accepted any means of assessing skin tightening — and it is not an FDA-approved procedure. Although there are many devices now available that nicely induce this clinical result, no marketing from any of these manufacturers ever mentions the term “tissue tightening”.
The prospect of being able to “tighten” skin and thus bring about diminution in lines and wrinkles with a non-invasive procedure is very seductive. Devices have generally been approved for diminution of the appearance of wrinkles, or for heating the skin, or for improving the tone and texture of the skin and improving tissue laxity.
The means by which non-invasive tissue tightening comes about is through heating the skin without damaging or removing the overlying epidermis. The heat induces both mechanical and biochemical effects that produce a tightening effect and a wound healing response with neocollagenesis. Because it is paramount that the outer aspects of skin be protected, most technologies incorporate a cooling mechanism so that heat may be deposited deeply while the epidermis remains cool and unaffected.
What’s Available
The ThermaCool device from Thermage was the first device approved in this category 8 years ago. This treatment is based on a monopolar radiofrequency system that produces volumetric heating of broad areas within the dermis as well as into the septae of the subcutaneous tissue. When this originally came on the market, it was thought that one or two passes at high intensities were the optimal treatment regimen.
Over time, this has been modified so that it is both more effective, less uncomfortable, and unlikely to bring about any side effects, with the use of low-intensity multiple-pass treatments.
The Polaris (Syneron) is a diode laser (780 nm to 980 nm) with bipolar radiofrequency using both light and radiofrequency (RF) energy to heat the dermis. Light and RF are thought to work synergistically, while cooling is found within the treatment tip. The primary indication for this technology has been for reduction of wrinkles.
More recently, Syneron has released the ReFirme, which combines infrared light (700 nm to 2000 nm) and bipolar radiofrequency.
Bipolar radiofrequency combined with a vacuum is the basis for the Aluma (Lumenis), which is FDA approved for the treatment of fine lines and wrinkles. As the skin is drawn up between two electrodes, skin between these electrodes may be able to be treated with lower energy levels, greater depth of penetration, increased safety and less pain.
The Titan (Cutera) emits light in 1100-nm to 1800-nm wavelength range through a cool window that is held in contact with skin. Some cutaneous contraction has been noted for up to 12 months post-treatment.
Fractional infrared energy is delivered through the infrared (IR) head of the StarLux IR (Palomar), which emits light from 850 nm to 1350 nm through a cold contact head. Several treatments are necessary to bring about remodeling of collagen.
Energy from 1064-nm lasers reach great depths within the dermis and this wavelength has been used in an attempt to bring about tissue tightening. The long-pulsed millisecond Nd:YAG laser has been shown to be effective in improving skin laxity in at least one study with improvement lasting for up to 6 months.
Common Threads of Tissue Tightening
All of the tissue tightening treatments involve heating the skin and thus are accompanied by varying degrees of discomfort. If the skin is heated over a certain threshold, or if the cooling mechanism is not appropriate or fails, cutaneous injury in the form of burns or pigmentary changes or contour changes may be seen. However, this is quite uncommon.
With many of these devices, it is possible to appreciate the appearance of immediate tissue tightening and contraction if only one side of the face is initially treated. Subsequent changes within skin brought about by thermal dermal injury continue to evolve over the next 6 months or more.
No controlled clinical studies exist that have compared one device with another and it is not possible to rank devices in order of efficacy. Indeed, it is often difficult to demonstrate efficacy, even when it is there, for there are no good methods to demonstrate quantitative tissue tightening. Three-dimensional imaging may be the best way to show these often-subtle changes. Although biochemical, histologic and electromicroscopic changes have been found after various tissue tightening treatments, the correlation between these findings and clinical efficacy is sometimes difficult to make.
Still on the Learning Curve
This technology is less than a decade old, and the clinical results are variable. Reliable, effective, reproducible, non-painful, non-invasive tissue tightening will be a valuable method of great utility to many patients. With further knowledge about proper usage and subsequent clinical and laboratory studies, we may be able to better understand this very interesting area and provide more realistic expectations.
Laser/Light Skin Resurfacing: What’s Next?
Jeffrey S. Dover, M.D., FRCPC
Ever since the early 1990s when CO2 laser resurfacing was developed, the search has been on for a technology that will equal the dramatic improvements in photoaging and acne scarring produced by CO2 resurfacing but without the significant side effects associated with it.
Non-ablative skin rejuvenation was created as the alternative to the frequent and significant complications experienced with CO2 laser skin resurfacing. Yet, although the mid-infrared devices at 1320 nm, 1440 nm and 1540 nm improved skin texture, improved acne scars somewhat better, and resulted in very well tolerated procedures that rarely had side effects — in general, the results of these treatments have been disappointing.
Newer Technologies for Resurfacing: The Answer?
Over the last few years, a variety of new ablative, and coagulative non-ablative laser-, light-, and energy-based technologies have been developed in an effort to achieve effective improvement of photoaging and acne scarring with an acceptable safety profile. These devices include variable pulse 2940-nm erbium:YAG laser resurfacing, 1540-nm and 1420-nm fractional erbium:YAG laser resurfacing, fractional 10,600-nm CO2 laser resurfacing and plasma skin rejuvenation.
Variable-pulsed erbium:YAG laser resurfacing. With this technology, the amount of energy can be dialed in to ablate predictable amounts of the epidermis and dermis. Termed the “micro laser peel”, the more energy delivered to the skin, the greater the wound, the longer the downtime, and the greater the degree of improvement.
Fractional resurfacing affects columns of skin, up to 100µ in diameter, which are thermally damaged, leaving completely unaltered areas of skin between the treated columns. The term “fractional” is used because only a fraction of the treated area is affected with each treatment. Redness and swelling after each procedure lasts an average of 3 days, depending on the device used. A series of five to six treatments is usually needed to achieve optimal improvement of sun-induced dyspigmentation, wrinkle reduction, or acne scarring.
Fractional CO2 laser resurfacing builds on the technical advances of fractional Er:YAG resurfacing. A scanner deposits an array of 120-micron diameter beams of CO2 laser energy. This energy vaporizes tiny columns of tissue. The result is not only improved color and texture but also skin tightening. Early studies predict that significant results will be attained with one or two treatments. The healing phase is a bit longer than with fractional erbium laser resurfacing — patients experience hemorrhage, crusting, swelling, and redness that lasts an average of about 1 week, depending on the treatment parameters.
In plasma skin rejuvenation, plasma, the fourth state of energy, generates heat in the epidermis and dermis, which results in coagulation that occurs in a graduated fashion to induce improvement to the skin. The degree of improvement to the skin is determined by the energy delivered and the number of passes. The procedure can be performed across a spectrum. At one end, the procedure can be done so gently that there is absolutely no discomfort and no post-operative downtime — but with limited improvement. At the other end of the spectrum, treatment is more painful and complete epidermal regeneration occurs with 10 days of downtime and quite dramatic improvements in both the color and texture of the skin.
Exploring the Potential of These Newer Treatments
Each of these procedures has the potential for:
• improving sun-induced skin color
• improving skin texture
• producing mild to modest skin tightening
• improving acne scarring.
Unlike traditional CO2 laser skin resurfacing, however, each procedure induces less oozing, less crusting, less scabbing, less erythema, a shorter healing time, and a much lower risk of side effects. None of these procedures has yet been reported to induce long-term hypopigmentation. In addition, while there may have been cases of infection or scarring, they have yet to be reported in the literature.
These procedures are easier for physicians to learn to perform, and far less painful and risky than CO2 laser skin resurfacing. So what is the trade-off? While we are getting closer, thus far, none of these alternative procedures have produced the kind of wrinkle reduction and skin tightening seen with traditional CO2 laser skin resurfacing.
The Choice Is Clear
Given our desire for safety combined with efficacy, most of us and our patients would prefer one of these less-involved, less-effective procedures to avoid the potential complications of CO2 laser skin resurfacing.
Adjunct Treatment for Recalcitrant Acne
Girish Munavalli, M.D., and Robert Weiss, M.D.
Photopneumatic therapy (PPx) using Aesthera’s second-generation device, Isolaz, has proven effective for our patients in a recent clinical trial we conducted in patients who have recalcitrant acne.
The device works by utilizing pulsed light concurrently with vacuum pressure. The proposed mechanisms of action for treating patients who have comedonal, nodulocystic and papulo-pustular facial acne are as follows:
1. works to treat acne by reducing sebaceous load and follicular plugging
2. uses pulsed light to selectively heat dermal structures, rapidly reducing pilosebaceous inflammation
3. activates Propionibacterium acnes porphyrins.
Recent Study Results with This Device
In a study of 15 patients who had recalcitrant acne, especially those with inflammatory papules, pustules and comedones, we conducted a series of four treatments with Isolaz. These patients had been undergoing treatment with topicals and antibiotics, and we introduced the concept of Isolaz to these patients right away to jumpstart their treatment. We did not focus on patients who hadn’t undergone conventional acne treatments.
During treatment with Isolaz, we made three to five passes with the device, which took about 20 minutes total. Patients underwent four treatments — one a week for four weeks — and then were evaluated 1 month post-treatment. (See photo above to view one of our patients who was treated.) No topical anesthesia was needed prior to the treatments, and afterward, patients experienced only mild transient redness along with a less than 5% incidence of purpura. There was no downtime with this procedure.
Some patients experienced dramatic improvement in their acne within one to two treatments, and all patients experienced at least moderate improvement within the first two treatments. One to 2 months following treatment, patients reported less skin oiliness and a decreased number of new acne lesions. Even female patients with hormone-sensitive acne reported less acne flaring along in conjunction with their menstrual cycles. So there is definitely some prolonged benefit after treatment ends.
We’re always trying to get patients to the maintenance phase of their acne treatment, and this treatment was beneficial. Overall, all of the patients seemed to get improvement to some degree, and patients have overall been satisfied with this treatment. n
Treating Port Wine Stains and Other Vascular Lesions
Elizabeth Tanzi, M.D.
For patients who have recalcitrant and hypertrophic port wine stains and other vascular lesions, a new technology that delivers a kind of “one-two punch” has demonstrated advantages over what is currently available. The Cynergy laser (Cynosure) with the MultiPlex feature delivers timed, sequential pulses of a 595-nm pulsed dye laser followed by 1064-nm Nd:YAG.
The initial absorption of the pulsed dye laser wavelength causes heating and subsequent conversion of oxyhemoglobin to methemoglobin. Methemoglobin is 3 to 5 times better able to absorb energy from the Nd:YAG laser at 1064 nm. With the two wavelengths — one followed immediately after the other — the MultiPlex feature allows deeper heating of the vessels, which is particularly helpful for hypertrophic port wine stains. This technology has been a great advance in my practice.
In a clinical study, Dr. Tina Alster and I treated 25 children and adults who had recalcitrant port wine stains (defined as minimal improvement after 10 or more pulsed dye laser treatments) with the Cynergy laser using the MultiPlex feature. Patients were treated at 6-week intervals using a 10-mm spot size and energies of 7.0 to 9.0 J/cm2 for the 595-nm PDL and 25 to 45 J/cm2 with the 1064-nm Nd: YAG. Pulse durations were 6 or 10 ms with the 595-nm wavelength and 1 ms with the Nd:YAG, with a delay of 0.5 to 1 second between pulses. Concomitant air cooling provided epidermal protection.
All of the patients in our study showed improvement of varying degrees. The majority of patients experienced edema and mild purpura; however, no patients exhibited vesicle formation, dyspigmentation or scarring.
Currently in my practice, the vast majority of my patients with telangiectasias, rosacea or port wine stains are receiving treatment with this device. (See photo.) I’ve found that this technology is more effective in treating these conditions than the pulsed dye laser alone and provides good clinical improvement with fewer treatment visits. n
A New Twist on Erbium Resurfacing
Amy Forman Taub, M.D.
The yttrium scandium gallium garnet (YSGG) provides a new twist on erbium resurfacing. Its different wavelength (2790 nm vs. 2940 nm) enables it to deliver efficient ablation and some coagulation, resulting in minimal post-operative oozing and no need for occlusive dressings.
Because of the reduced post-operative morbidity and consistent results, the YSGG has been a patient-pleasing addition to our armamentarium for the subset of patients who want fast results for both mild wrinkling and photodamage and are willing to put up with a short period of downtime.
Dubbed the Pearl by Cutera, Inc, this laser utilizes a wavelength that is off the peak of water absorption. The advantage of this is that it still ablates very effectively, but also delivers some coagulation. This translates into vaporization of the epidermis and a mild heating of the upper dermis, potentially yielding more collagen induction than with traditional erbium alone. With this procedure, a layer of coagulated epidermis remains intact after treatment, serving as a “natural dressing” that hinders oozing and bleeding and eliminates the need for hydrocolloid dressings post-operatively.
Downtime is limited to 3 to 4 days with minimal discomfort and no need for complex skin care. By day 4 make up will conceal the fact that a procedure was done, although some peeling usually occurs for 5 to 10 days. Within 1 to 2 weeks, the skin is completely healed and with it enough of an improvement that the patients’ friends and family members notice the positive change.
There is no prolonged post-operative erythema or hypo- or hyper-pigmentation as long as a single-pass protocol is observed.
The Pearl isn’t for deep rhytides or anything but the most superficial acne scars. But for that niche of patients who want to be refreshed, don’t want multiple treatments, have mild rhytides, mild-to-moderate solar elastosis and are willing to experience a short downtime, this technology offers a great choice.
This twist on an older technology (superficial erbium resurfacing), which was unpalatable to most of our patients, has led to less downtime and pain, no dressings and low risk. By using the proper parameters and no more than one pass, this effective and safe new erbium treatment has become a commonly performed and popular procedure in our office.
