Minimally invasive skin rejuvenation with Erbium: YAG laser used in thermal mode

Fox eyes lift-A new protocol for eyebrow elevation with laser Fotona

BACKGROUND

The eyelids play an important role in our appearance and are usually the first to show signs of age. The Fotona SP Spectro Systems consist of a range of noninvasive laser treatments that work together synergistically to tighten the collagen in four dimensions and provide long-lasting firmness to the face. The Fotona SP Spectro combines two wavelengths: Er:YAG (2940 nm) and Nd:YAG (1064 nm) with four distinct treatments: SmoothLiftingTM, FRAC3®, PIANO®, and SupErficialTM, allowing safe, painless, noninvasive, and no downtime rejuvenation.

AIMS

To present a new protocol of treatment with Fotona SP Spectro for eyebrow elevation, which we call fox eyes lift (FEL), and compare it to the standard SmoothEye® (SE) protocol.

METHODS

This is a prospective, interventional, split-face study. The sample consisted of 21 subjects (19 women) with a mean age of 50.1 ± 7.9 years who underwent two different protocols, that is, SE on one side and FEL on the other. The protocol used on each side was selected by drawing lots. Three sessions were held at 1-month intervals. Standardized photographic documentation was obtained before and 30 days after the end of treatment. Eyebrow position before and after complete treatment was quantified using ImageJ software.

RESULTS

Statistical analysis by ANOVA showed a significant improvement in eyebrow position after treatment with both protocols, with a significantly greater effect of FEL (p = 0.0003 d = 0.95).

CONCLUSION

Fox eyes lift is an efficient and safe technique providing significant improvement in the position of the eyebrow.

Influence of tissue desiccation on critical temperature for thermal damage during Er:YAG laser skin treatments

OBJECTIVES

Erbium lasers have become an accepted tool for performing both ablative and non-ablative medical procedures, especially when minimal invasiveness is desired. Hard-tissue desiccation during Er:YAG laser procedures is a well-known phenomenon in dentistry, the effect of which is to a certain degree being addressed by the accompanying cooling water spray. The desiccation of soft tissue has attracted much less attention due to the soft tissue's high-water content, resulting in a smaller effect on the ablation process.

MATERIALS AND METHODS

In this study, the characteristics of skin temperature decay following irradiations with Er:YAG laser pulses were measured using a fast thermal camera.

RESULTS

The measurements revealed a substantial increase in temperature decay times and resulting thermal exposure times following irradiations with Er:YAG pulses with fluences below the laser ablation threshold. Based on an analytical model where the skin surface cooling time is calculated from the estimated thickness of the heated superficial layer of the stratum corneum (SC), the observed phenomena is attributed to the accelerated evaporation of water from the SC's surface. By using an Arrhenius damage integral-based variable heat shock model to describe the dependence of the critical temperature on the duration of thermal exposure, it is shown that contrary to what an inexperienced practitioner might expect, the low-to-medium level fluences may result in a larger thermal damage in comparison to treatments where higher fluences are used. This effect may be alleviated by hydrating the skin before Er:YAG treatments.

CONCLUSION

Our study indicates that tissue desiccation may play a more important role than expected for soft-tissue procedures. It is proposed that its effect may be alleviated by hydrating the skin before Er:YAG treatments.

Fractional CO2 laser treatment for women with stress predominant urinary incontinence: a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

To evaluate the efficacy of vaginal CO2 laser in women with stress predominant urinary incontinence (SUI) compared with the sham treatment.

METHODS

A randomized controlled trial with sham treatment was conducted between January 2019 and April 2021. Women with predominant SUI were recruited and randomized into two groups: the CO2 laser group (n = 29) and the sham group (n = 30). The International Consultation on Continence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) was used to evaluate the efficacy at 3 months postoperatively. All participants in both groups were advised to perform pelvic floor muscle training (PFMT) after the intervention.

RESULTS

A total of 59 women were studied. A total of 29 women were included in the CO2 laser group and 30 women were included in the sham group. The baseline scores of the ICIQ-UI SF were similar in both groups. A significant improvement in urinary incontinence scores was found in both groups 3 months after treatment (p < 0.001). However, there were no statistically significant differences between the two groups at 3 months (p = 0.8281). There were no changes in bladder neck descent or levator hiatal area immediately after intervention or 3 months after completion of treatment in either group. Most participants who received the active intervention reported mild vaginal pain during the procedure that resolved spontaneously at the end of treatment.

CONCLUSIONS

Fractional CO2 laser treatment does not provide any benefit over the sham technique in alleviating SUI symptoms. The improvement in SUI symptoms in both groups might be related to PFMT. This study was registered with the Thai Clinical Trial Register (TCTR20190131004).

Emerging High-Frequency Ultrasound Imaging in Medical Cosmetology

Cosmetic skin diseases are a part of many dermatological concerns brought up by patients, which negatively affect mental health and quality of life. Imaging technology has an established role in the diagnosis of cosmetic skin diseases by recognizing information on deep skin lesions. Due to the complex physiological and pathological nature of cosmetic skin diseases, the diagnostic imaging performance varies greatly. Developing noninvasive technology models with wide applicability, particularly high-frequency ultrasound (HFUS), which is able to achieve high-resolution imaging of the skin from the stratum corneum down to the deep fascia, is of great significance to medical cosmetology. To explore the great potential of HFUS in cosmetic skin diseases, a narrative review of literature from PubMed and Web of Science published between 1985 and 2022 was conducted. This narrative review focuses on the progression of HFUS imaging in medical cosmetology, especially on its promising application in the quantitative evaluation and differential diagnosis of cutaneous pathological scar, port wine stain (PWS), acne, skin aging, and other cosmetic applications.

Changes in sexual function and vaginal topography using transperineal ultrasound after vaginal laser treatment for women with stress urinary incontinence

We aim to assess the changes in sexual function and vaginal topography using 3-D transperineal ultrasound in stress-incontinent women treated with Er:YAG vaginal laser. Two hundred and twenty women with stress urinary incontinence (SUI) treated with Er:YAG laser were recruited. Assessment before and 6 months after the treatment included vaginal topography using 3-D transperineal ultrasound and sexual function using female sexual function index questionnaire (FSFI). A total of 50 women with complete data showed that the symptomatic improvement was noted in 37 (74%) women. After Er:YAG vaginal laser treatment, significantly decreased width and cross-sectional area in proximal, middle, and distal vagina were found in women with SUI. Nearly all of the domains of FSFI improved significantly after the vaginal laser treatment, except sexual desire. In conclusion, 3-D transperineal ultrasound can be used to conduct vaginal topography. After Er:YAG vaginal laser treatment, the anatomical changes of vaginal shrinkage and the improvement of female sexual function were both noted. The favorable outcome of sexual function partly related to the tightening of vagina, as evidenced by the measurements of the 3-D transperineal ultrasound.

The Er:YAG vaginal laser for management of women with genitourinary syndrome of menopause (GSM)

The purpose of our study was to investigate the effects of vulvovaginal erbium laser on the genitourinary syndrome of menopause (GSM) and sexual function of postmenopausal women. We conducted a retrospective study of sixty-four postmenopausal women with GSM, and these patients were scheduled for three times of vulvovaginal erbium laser treatment. A baseline and post-treatment vaginal status was assessed by measuring vaginal pH, patients' subjective vulvovaginal atrophy (VVA) symptoms, which included dryness, dyspareunia, itching, and burning. The urinary response to treatment was assessed using ICIQ-SF, UDI-6, IIQ-7, OABSS, and POPDI-6. Sexual function was evaluated using the Female Sexual Function Index (FSFI) before and after vulvovaginal laser therapy. Patient follow-ups were scheduled for 12 months after treatment. A total of sixty-four patients were enrolled in the study. We observed the significant improvement in the percentage of negative symptoms (dryness/dyspareunia/itching/burning) and in lower urinary tracts symptoms evaluated with ICIQ-SF, UDI-6, IIQ-7, OABSS, and POPDI-6 (P < 0.05). Patients' overall satisfaction regarding their sexual life, assessed via Female Sexual Function Index (FSFI), showed significant improvement in its six domains of sexual function (P < 0.05). The pH level of vaginal secretions significantly decreased. No long-term complications were found post-treatment. The Er:YAG vaginal laser procedure is associated with a significant improvement in GSM and sexual function of postmenopausal women. Our result demonstrates that it can be a safe and efficacious treatment for patients with GSM without any serious adverse effects up to 1-year post-treatment. The long-term effects of using vulvovaginal laser in the treatment of GSM should be investigated.

Assessing Light and Energy-Based Therapy by Optical Coherence Tomography and Reflectance Confocal Microscopy: A Randomized Trial of Photoaged Skin

BACKGROUND AND OBJECTIVES

Image-guided quantitative and semi-quantitative assessment of skin can potentially evaluate treatment efficacy. Optical coherence tomography (OCT) and reflectance confocal microscopy (RCM) are ideal for this purpose. This study assessed clinically relevant statistical changes in RCM and OCT features in photoaged skin after light and energy-based therapy.

METHODS

Novel statistical analyses were performed using OCT and RCM data collected during a previously published trial: a 12-week study of female décolleté skin randomized to four areas treated with thulium laser (L), photodynamic therapy (PDT), combined L-PDT, and control. Eight semi-quantitative RCM scores of photodamage and OCT measurements of skin roughness, blood flow, and epidermal thickness (ET) were evaluated and compared to dermoscopy and clinical skin scores. In statistical analysis, estimated treatment difference (ETD) was calculated.

RESULTS

Twelve women with moderate to severe photodamage were included. RCM and OCT data demonstrated a trend towards rejuvenation of epidermis with increased ET, changes in skin surface, and improved honeycomb pattern in RCM. In angiographic OCT, non-significant changes towards more regular capillary meshes were shown, which matched a decline in appearance of gross telangiectasias in dermoscopy. Improved skin tone after laser and L-PDT was identified in RCM, showing less edged papillae in 36% and 45%, and lentigo number declined in 55% of patients after treatments in dermoscopy. Based on clinical scores, L-PDT provided the greatest clinical improvement, which corresponded to superior ETD outcomes in ET and edged papillae shown in OCT and RCM, respectively.

CONCLUSION

Objective OCT and RCM assessment of skin rejuvenation was demonstrated in this study. Importantly, image-based improvements corresponded to favorable clinical skin scores and fewer photoaging characteristics in dermoscopy. Importantly, most changes did not reach statistical significance, prompting further studies and emphasizing the modest value of non-randomized, non-blinded anti-aging trials.

Effectiveness and Safety of Combined Application of Three Modes of 2940-nm Erbium:YAG and 1064-nm Neodymium:YAG Lasers in Treatment of Meibomian Gland Dysfunction

Purpose

To study the effectiveness and safety of upper and lower eyelid treatment with combined application of three modes of 2940-nm erbium-doped yttrium aluminium garnet (Er:YAG) and 1064-nm neodymium-doped yttrium aluminium garnet (Nd:YAG) lasers in patients with baggy eyelids (formed by intraorbital fat herniation) who exhibited meibomian gland dysfunction (MGD).

Patients and Methods

In this prospective cohort study, patients with baggy eyelid who exhibited MGD received combined laser treatment at baseline, as well as at the 4-, 8-, and 12-week follow-ups. The primary endpoint was meibum quality score at 16- and 24-week follow-ups; secondary endpoints were ocular surface index scores, tear film lipid layer thicknesses, tear break up times (TBUTs), Oxford scheme grades, and meibography grades at 16- and 24-week follow-ups. Adverse events, uncorrected visual acuities, best-corrected visual acuities, and intraocular pressures were also recorded.

Results

Sixteen patients (four men and 12 women; mean age, 56.38 ± 8.64 years) were included. Meibum quality scores at the 16-week follow-up were significantly lower than scores at baseline (p=0.043) and at the 24-week follow-up (p=0.015). TBUT was significantly exacerbated at the 24-week follow-up, compared with baseline (p=0.001) and the 16-week follow-up (p=0.006). There were no significant changes in other parameters. All adverse events were mild and resolved without additional treatment.

Conclusion

Combined application of three modes of 2940-nm Er:YAG and 1064-nm Nd:YAG lasers on upper and lower eyelids significantly improved meibum quality in patients with MGD; it ameliorated symptoms and signs of dry eye disease at 4 weeks after completion of laser treatment.

A plea for standardization of confocal microscopy and optical coherence tomography parameters to evaluate physiological and para-physiological skin conditions in cosmetic science

Non-invasive reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) have been extended to the dermo-cosmetic field, for skin pathophysiology understanding and therapeutics monitoring. However, standardized methodology and parameters to interpret structures and changes in these settings are still lacking. Present study aimed to propose a validated standard methodology and a list of defined parameters for objective non-pathological skin assessments in the cosmetically sensitive cheekbone area of the face. OCT and RCM quantitative, semi-quantitative and qualitative features were considered for assessments. Validation process included 50 sets of images divided into two age groups. Inter-rater reliability was explored to assess the influence of the proposed methodology. Quantitative OCT parameters of "epidermal thickness," "density and attenuation coefficients" and "vascular density" were considered and calculated. Severity scales were developed for semi-quantitative OCT features of "disruption of collagen" and "vascular asset," while extent scales were produced for semi-quantitative RCM "irregular honeycomb," "mottled pigmentation" and "polycyclic papillary contours." Qualitative assessment was obtained for RCM type of collagen, and comparison between age groups was performed for all features considered. Severity visual scales assistance proved excellent inter-rater agreement across all semi-quantitative and qualitative domains. The assistance of shareable software systems allows for objective OCT quantitative parameters measurement. The use of standard reference scales, within a defined assessment methodology, offers high inter-rater reliability and thus reproducibility for semi-quantitative and qualitative OCT and RCM parameters. Taken together, our results may represent a starting point for a standardized application of RCM and OCT in dermo-cosmetic research and practice.

Characteristics of Non-Ablative Resurfacing of Soft Tissues by Repetitive Er:YAG Laser Pulse Irradiation

Background and Objectives

Recently, several minimally invasive gynecological, ENT and esthetic procedures have been introduced that are based on delivering “smooth” sequences of Er:YAG laser pulses to cutaneous or mucosal tissue at moderate cumulative fluences that are not only below the ablation threshold but typically also do not require local anesthesia.  To explain the observed clinical results using “smooth‐resurfacing,” it has been suggested that in addition to the direct heat injury to deeper‐lying connective tissues, there is an additional mechanism based on indirect triggering of tissue regeneration through short‐exposure, intense heat shocking of epithelia. The goal of this study is to improve understanding of the complex dynamics of the exposure of tissues to a series of short Er:YAG laser pulses, during which the thermal exposure times transition from extremely short to long durations.

Study Design/Materials and Methods

A physical model of laser‐tissue interaction was used to calculate the temperature evolution at the irradiated surface and deeper within the tissue, in combination with a chemical model of tissue response based on the recently introduced variable heat shock (VHS) model, which assumes that the tissue damage represents a combined effect of two limiting Arrhenius′ processes, defining cell viability at extremely long and short exposure times. Superficial tissue temperature evolution was measured during smooth‐resurfacing of cutaneous and mucosal tissue, and compared with the model. Two modalities of non‐ablative resurfacing were explored: a standard “sub‐resurfacing” modality with cumulative fluences near the ablation threshold, and the “smooth‐resurfacing” modality with fluences below the patient′s pain threshold. An exemplary skin tightening clinical situation was explored by measuring pain tolerance threshold fluences for treatments on abdominal skin with and without topical anesthesia. The obtained temperature data and pain thresholds were then used to study the influence of Er:YAG laser sequence parameters on the superficial (triggering) and deep (coagulative) tissue response.

Results

The simulations show that for the sub‐resurfacing modality, the parameter range where no excessive damage to the tissue will occur is very narrow. On the other hand, using pain tolerance as an indicator, the smooth‐resurfacing treatments can be performed more safely and without sacrificing the treatment efficacy. Two preferred smooth‐resurfacing treatment modalities were identified. One involves using optimally long pulse sequence durations (≈1–3 seconds) with an optimal number of pulses (N ≈ 10–30), resulting in a maximal short‐exposure superficial tissue response and moderate coagulation depths. And for deeper coagulation, without significant superficial heat shocking, very long pulse sequences (>5 seconds) with a large number of delivered pulses are to be used in combination with topical anesthesia.

Conclusions

A comparison of the simulations with the established smooth‐resurfacing clinical protocols in gynecology, ENT, and esthetics suggests that, through clinical experience, the clinical protocols have been optimized for the maximal superficial heat shock triggering effect. Further research is needed to gain a better understanding of the proposed role of heat shock triggering in the clinically observed regeneration of cutaneous, vaginal, and oral tissues following Er:YAG laser smooth‐resurfacing. Lasers Surg. Med. © 2021 The Authors. Lasers in Surgery and Medicine published by Wiley Periodicals LLC.

Management of skin thinning and aging: review of therapies for neocollagenesis; hormones and energy devices

BACKGROUND

Hormone replacement therapy and various devices exist to treat signs of aging, such as skin thinning, yet there are no reviews summarizing or evaluating their role in neocollagenesis and the associated increase in skin thickness.

OBJECTIVE

To review the literature regarding stimulation and generation of new collagen in the dermis in two parts. Part 2 reviews oral and topical hormone replacement therapy as well as energy-based devices.

METHODS

The PubMed database was searched for related literature. Studies involving the use of hormone supplements and energy devices with a resultant change in collagen production or skin thickness were obtained and reviewed for evidence.

RESULTS

Hormones, including estrogen, testosterone, and dehydroepiandrosterone, and human growth hormone have been reported with substantiating evidence for neocollagenesis and dermal thickening. Energy devices, including radiofrequency, ultrasound, and laser therapy, have also been reported to stimulate neocollagenesis.

LIMITATIONS

The results presented in certain literature are not based on randomized controlled trials.

CONCLUSION

Hormone deficient individuals can regain skin thickness with hormone replacement therapy. Dermal heating can provide a substantial amount of neocollagenesis; however, laser technology, specifically CO₂ , appears to be the most effective at increasing skin collagen and tightening.

Optical coherence tomography for fast bedside imaging, assessment and monitoring of autoimmune inflammatory skin diseases?

Optical coherence tomography (OCT) is a non-invasive, high-resolution imaging technique with a growing impact in dermatology. The principle of OCT is comparable to that of sonography, except that it uses infrared laser light instead of ultrasound waves. It has been clinically demonstrated that OCT is suitable for discriminating between different types of non-melanoma skin cancer at an early stage of disease. Optical coherence tomography generates two- or three-dimensional images of up to 2 mm penetration depth, a field of view of 6 mm × 6 mm, and an acquisition time of seconds. The resolution capability of OCT is more than 3 to 100 times higher than that of ultrasound imaging. It is of particular interest that the additional information on vasculature provided by OCT angiography enables the assessment and monitoring of inflammatory skin diseases. The use of OCT to locate exact blister levels was demonstrated for diagnosing autoimmune bullous diseases. It is anticipated that detection of subclinical lesions could indicate a relapse of the disease. In the future, this could enable intervention and early treatment. Furthermore, the development of high-speed OCT could allow fast scanning and bedside imaging of large body sites.

Effects of non-ablative Er:YAG laser on the skin and the vaginal wall: systematic review of the clinical and experimental literature

INTRODUCTION AND HYPOTHESIS

Er:YAG laser is frequently used in dermatology and gynecology. Clinical studies document high satisfaction rates; however, hard data on the effects at the structural and molecular levels are limited. The aim of this systematic review was to summarize current knowledge about the objective effects of non-ablative Er:YAG laser on the skin and vaginal wall.

METHODS

We searched MEDLINE, Embase, Cochrane, and the Web of Science. Studies investigating objectively measured effects of non-ablative Er:YAG laser on the skin or vaginal wall were included. Studies of any design were included. Owing to the lack of methodological uniformity, no meta-analysis could be performed and therefore results are presented as a narrative review.

RESULTS

We identified in vitro or ex vivo studies on human cells or tissues, studies in rats, and clinical studies. Most studies were on the skin (n = 11); the rest were on the vagina (n = 4). The quality of studies is limited and the settings of the laser were very diverse. Although the methods used were not comparable, there were demonstrable effects in all studies. Immediately after application the increase in superficial temperature, partial preservation of epithelium and subepithelial extracellular matrix coagulation were documented. Later, an increase in epithelial thickness, inflammatory response, fibroblast proliferation, an increase in the amount of collagen, and vascularization were described.

CONCLUSIONS

Er:YAG laser energy may induce changes in the deeper skin or vaginal wall, without causing unwanted epithelial ablation. Laser energy initiates a process of cell activation, production of extracellular matrix, and tissue remodeling.

Laser procedure for female urinary stress incontinence: A review of the literature

INTRODUCTION

There is increasing interest in noninvasive treatment of female stress urinary incontinence (SUI), including a vaginal laser procedure. In view of a lack of data on this technique, we conducted a non-systematic review of the literature.

METHODS

We reviewed studies concerning the laser treatment of SUI from PubMed, Medline, the Cochrane Library and Web of Science. Study design, outcome measure, number of participants, procedural complications and results were analyzed.

RESULTS

The use of laser treatment of female SUI has been described in 7 prospective, single-center and non-comparative (no control group) studies, all of which used an erbium YAG or a CO2 laser in thermal non-ablative treatment. Primary outcome was ICIQ-UI-SF score in six studies, and pad tests in one study. Follow-up ranged from 5 to 36months. Improvement rates ranged from 62% to 78%. No major adverse events were noted. Minor side effects included sensation of warmth, increased vaginal discharge and transient urge urinary incontinence.

CONCLUSION

The efficacy of vaginal laser treatment of SUI has not been assessed in comparative studies. More rigorous and adequately powered trials are required to assess the relative benefits and adverse event profile of laser treatment of SUI, as compared with other minimally invasive procedures.

Long-term effect of thermoablative fractional CO2 laser treatment as a novel approach to urinary incontinence management in women with genitourinary syndrome of menopause

Introduction and hypothesis

The aim of this study was to evaluate the long-term effect of thermoablative fractional CO₂ laser (TACO2L) as an alternative treatment for early stages of stress urinary incontinence (SUI) in postmenopausal women with genitourinary syndrome of menopause.

Methods

A total of 161 postmenopausal patients (age 53.38 ± 5.1 years, range 45–65 years) with a clinical diagnosis of mild SUI were prospectively enrolled in the study. Patients received one treatment with TACO2L every 30–45 days, each treatment comprising four sessions, followed in all patients by a yearly treatment session at 12, 24 and 36 months. SUI was evaluated using the International Continence Society 1-h pad test and the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) before and after TACO2L treatment.

Results

TACO2L treatment was associated with a significant improvement in ICIQ-UI SF scores and 1-h pad weight test at 12 months (both p < 0.001), 24 months (both p < 0.001) and 36 months (both p < 0.001). Improvements were maintained for up to 36 months without the need for any further intervention. The results were confirmed by significant histological changes related to trophic restoration of the vagina, responsible for extrinsic and intrinsic mechanisms involved in urinary continence.

Conclusions

Our results suggest that TACO2L is an efficient and safe novel treatment strategy in patients with mild SUI. Further investigation to confirm the long-term results presented here is still warranted.

Effects of laser procedure for female urodynamic stress incontinence on pad weight, urodynamics, and sexual function

INTRODUCTION AND HYPOTHESIS

The impact of the IncontiLase^TM procedure on lower urinary tract symptoms (LUTS) remains unclear. Our aim was to evaluate the effects of the IncontiLase^TM procedure for urodynamic stress incontinence (USI).

METHODS

All consecutive women with USI prospectively underwent the IncontiLase^TM procedure. Urodynamic studies, pad testing, LUTS, and sexual function questionnaires were assessed before and after treatment.

RESULTS

Thirty-five women underwent the IncontiLase^TM procedure. Among the 28 women with baseline pad weights >1 g, 11 (39.3 %) were objectively cured and 11 (39.3 %) improved. Among the 18 women with mild USI (i.e., baseline pad weight 1-10 g), nine (50 %) were cured and five (27.8 %) improved. Among ten women with baseline pad weight >10 g, two (20 %) were cured and six (60 %) improved. Among the 32 women with complete questionnaire data at 6 months, seven (21.9 %) were subjectively cured, and four (12.5 %) improved. Regarding LUTS, the majority of domains on the King's Health Questionnaire and female sexual desire and function exhibited significant improvements. Forty percent (12/30) of the partners of these patients felt their sexual function had improved at 6 months. Nonetheless, urodynamic values did not differ across the timeline.

CONCLUSIONS

The effect of the IncontiLase^TM procedure for mild USI was moderate at 6-month follow-up but was not effective for pad weight >10 g. Moreover, it improved LUTS, quality of life, QoL, and sexual function of both partners. Further studies should be performed to assess long-term sustained efficacy.

Efficacy of Erbium:YAG laser treatment compared to topical estriol treatment for symptoms of genitourinary syndrome of menopause

Objectives

The objective of this prospective comparative cohort study was to establish the effectiveness and safety of Erbium:YAG (Er:YAG) laser treatment for genitourinary syndrome of menopause and to compare it with an established topical estriol treatment.

Methods

Fifty patients with genitourinary syndrome of menopause were divided into two groups. The estriol group received a treatment of 0.5 mg estriol ovules for 8 weeks and the laser group was first treated for 2 weeks with 0.5 mg estriol ovules 3 times per week to hydrate the mucosa and then received three sessions with 2,940 nm Er:YAG laser in non‐ablative mode. Biopsies were taken before and at 1, 3, 6, and 12 months post‐treatment. Maturation index, maturation value and pH where recorded up to 12‐months post‐treatment, while the VAS analysis of symptoms was recorded up to 18 months post‐treatment.

Results

Statistically significant (P < 0.05), reduction of all assessed symptoms was observed in the laser group at all follow‐ups up to 18 months post‐treatment. Significant improvement in maturation value and a decrease of pH in the laser group was detected up to 12 months after treatment. The improvement in all endpoints was more pronounced and longer lasting in the laser group. Histological examination showed changes in the tropism of the vaginal mucosa and also angiogenesis, congestion, and restructuring of the lamina propria in the laser group. Side effects were minimal and of transient nature in both groups, affecting 4% of patients in the laser group and 12% of patients in the estriol group.

Conclusions

Our results show that Er:YAG laser treatment successfully relieves symptoms of genitourinary syndrome of menopause and that the results are more pronounced and longer lasting compared to topical estriol treatment. Lasers Surg. Med. 49:160–168, 2017. © 2016 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.

Minimally invasive, non-ablative Er:YAG laser treatment of stress urinary incontinence in women--a pilot study

The study presents an assessment of mechanism of action and a pilot clinical study of efficacy and safety of the Er:YAG laser for the treatment of stress urinary incontinence (SUI). The subject of this study is a treatment of SUI with a 2940 nm Er:YAG laser, operating in a special SMOOTH mode designed to increase temperature of the vaginal mucosa up to maximally 60–65 °C without ablating the epidermis. Numerical modelling of the temperature distribution within mucosa tissue following an irradiation with the SMOOTH mode Er:YAG laser was performed in order to determine the appropriate range of laser parameters. The laser treatment parameters were further confirmed by measuring in vivo temperatures of the vaginal mucosa using a thermal camera. To investigate the clinical efficacy and safety of the SMOOTH mode Er:YAG laser SUI treatment, a pilot clinical study was performed. The study recruited 31 female patients suffering from SUI. Follow-ups were scheduled at 1, 2, and 6 months post treatment. ICIQ-UI questionnaires were collected as a primary trial endpoint. Secondary endpoints included perineometry and residual urine volume measurements at baseline and all follow-ups. Thermal camera measurements have shown the optimal increase in temperature of the vaginal mucosa following treatment of SUI with a SMOOTH mode Er:YAG laser. Primary endpoint, the change in ICIQ-UI score, showed clinically relevant and statistically significant improvement after all follow-ups compared to baseline scores. There was also improvement in the secondary endpoints. Only mild and transient adverse events and no serious adverse events were reported. The results indicate that non-ablative Er:YAG laser therapy is a promising minimally invasive non-surgical option for treating women with SUI symptoms.

Optical Coherence Tomography Imaging of Normal, Chronologically Aged, Photoaged and Photodamaged Skin: A Systematic Review

BACKGROUND

Optical coherence tomography (OCT) is capable of providing a noninvasive real-time cross-sectional image of the skin through light-based interferometry, a method sometimes described as "light-based ultrasound." One key application of OCT in dermatology is the visualization of dermal collagen during chronological aging, photoaging, or photodamage. These skin conditions are typically managed by the practitioner's subjective assessment of severity and response to therapy.

OBJECTIVE

The purpose of this review is to present available evidence on the ability of OCT to image normal, chronologically aged, photoaged and photodamaged skin in human subjects.

METHODS AND MATERIALS

The authors have searched Medline, PubMed, EMBASE, Web of Science, Google Scholar, and Cochrane Library databases for published literature on the imaging of skin collagen by OCT using the following search terms: "optical coherence tomography," "OCT," "skin," "collagen," "photoaging," "wrinkles," and "photodamage."

RESULTS

The search resulted in 23 articles investigating OCT-based skin collagen imaging, which met their search criteria.

CONCLUSION

The authors anticipate tremendous growth in the field of OCT-based skin imaging that will parallel the development ultrasound technology has experienced over the past 30 years. They foresee that the use of OCT imaging to evaluate skin aging will not only help identify pathological changes earlier, but will also assist in the evaluation of the response to therapy longitudinally without biopsy.

Novel minimally invasive laser treatment of urinary incontinence in women

BACKGROUND AND OBJECTIVE

Urinary incontinence (UI) is a common disorder that affects women of various ages and impacts all aspects of life. Our aim was to evaluate the non-invasive erbium:yttrium-aluminum-garnet (Er:YAG) laser that exploits its thermal effect and has been used in reconstructive and rejuvenation surgery as a potential treatment strategy for stress UI (SUI) and mixed UI (MUI).

STUDY DESIGN/MATERIALS AND METHODS

We included 175 women (aged 49.7 ± 10 years) with newly diagnosed SUI (66% of women) and MUI (34%), respectively. Patients were clinically examined and classified by incontinence types (SUI and MUI) and grades (mild, moderate, severe, and very severe) using International Consultation on Incontinence Modular Questionnaire (ICIQ) and assessing Incontinence Severity Index (ISI). Using Er:YAG laser, we performed on average 2.5 ± 0.5 procedures in each woman separated by a 2 month period. At each session, clinical examination was performed, ICIQ and ISI assessed and treatment discomfort measured with visual analog system (VAS) pain scale, and adverse effects and patients' satisfaction were followed. Follow-ups were performed at 2, 6, and 12 months after the treatment.

RESULTS

After the treatment, ISI decreased for 2.6 ± 1.0 points in patients diagnosed with mild UI before the treatment, for 3.6 ± 1.4 points in those with moderate UI, for 5.7 ± 1.8 points in those with severe UI and for 8.4 ± 2.6 in those with very severe UI (P < 0.001, paired samples t-test). Altogether, in 77% patients diagnosed with SUI, a significant improvement was found after treatment, while only 34% of women with MUI exhibited no UI at one year follow-up. Age did not affect the outcome. No major adverse effects were noticed in either group.

CONCLUSION

The results of our study, have shown that new non-invasive Er:YAG laser could be regarded as a promising additional treatment strategy for SUI with at least one year lasting positive effects. On the other hand, it does not seem appropriate for treating MUI.

Optical coherence tomography (OCT) of collagen in normal skin and skin fibrosis

Optical coherence tomography (OCT) is a non-invasive imaging modality that is transforming clinical diagnosis in dermatology and other medical fields. OCT provides a cross-sectional evaluation of the epidermis and dermis and allows in vivo imaging of skin collagen. Upregulated collagen content is a key feature of fibrotic skin diseases. These diseases are often managed by the practitioner's subjective assessment of disease severity and response to therapies. The purpose of this review is to provide an overview of the principles of OCT and present available evidence on the ability of OCT to image skin collagen in vivo for the diagnosis and management of diseases characterized by skin fibrosis. We review OCT studies that characterize the collagen content in normal skin and fibrotic skin diseases including systemic sclerosis and hypertrophic scars secondary to burn, trauma, and other injury. We also highlight several limitations of OCT and suggest enhancements to improve OCT imaging of skin fibrosis. We conclude that OCT imaging has the potential to serve as an objective, non-invasive measure of collagen's status and disease progression for use in both research trials and clinical practice. The future use of OCT imaging as a quantitative imaging biomarker of fibrosis will help identify fibrosis and facilitate clinical examination in monitoring response to treatment longitudinally without relying on serial biopsies. The use of OCT technology for quantification of fibrosis is in the formative stages and we foresee tremendous growth potential, similar to the ultrasound development paradigm that evolved over the past 30 years.

Photodamage: treatments and topicals for facial skin

This article provides an overview of current therapies for photodamaged facial skin and their efficacy, with particular focus on studies that use the objective, quantitative evaluation methods discussed in the previous article. The role of topically applied agents including prescription drugs and cosmetics is discussed. From this information, a schema for the relative effectiveness of therapeutic modalities in reducing perceived age is presented. This information assists the facial plastic surgeon in evaluating patient expectations and selecting the most effective program.

A new multi-modal fractional ablative CO2 laser for wrinkle reduction and skin resurfacing

BACKGROUND

The concept of fractional delivery modality of the energy with both ablative and non-ablative devices is now well known and accepted as an effective method to attain significant aesthetic improvements on facial aging skin. A new, multi-modal, fractional, ablative CO2 laser that can create, using same scanner/handpiece, deep columns in addition to superficial ablation has been recently proposed and therefore investigated.

METHOD

Twenty-four patients were enrolled in this evaluation. Each of them received one multi-modal, fractional ablative treatment. Patients were clinically and photographically evaluated at baseline and 6 months after the procedure. The degree of photoaging and the efficacy of treatment were evaluated using a VAS five-point scale of some skin features. A 3D images comparison was furthermore performed to objectify the improvements.

RESULTS

For all of the analysed skin features of photodamage a significant, statistical improvement was obtained. The data collected with the 3D system demonstrated an average improvement of 42% of the wrinkles and an average improvement of the melanin variation of 40.1%.

CONCLUSIONS

The multi-modal approach with a single handpiece allows obtaining good outcomes with a very low incidence of adverse effects and a short downtime.

Update on techniques for the quantitation of facial skin characteristics

The purpose of this article is to review the strategies and methods for quantifying treatment outcomes, perhaps defined by the consumer/patient as a "decrease in perceived age." The demand for the rejuvenation of facial skin is expected to increase as the population ages and seeks optimal outcomes from the array of available treatment modalities. This information will be of value to the plastic surgeon in collaborating with patients on evaluation and treatment strategies.

Multiple minimally invasive Erbium: Yttrium Aluminum Garnet laser mini-peels for skin rejuvenation: an objective assessment

BACKGROUND

As the demand for minimally invasive rejuvenation is increasing, micropeel resurfacing using Erbium:Yttrium Aluminum Garnet (Er:YAG) laser 2940 nm has been reported for the treatment of photoaged skin without ablation of the epidermis. However, little is known about the efficacy and underlying histologic changes associated with this type of treatment.

AIMS

The aims of this study are to evaluate the clinical effect and objectively quantify the histological changes in response to multiple sessions of Er:YAG laser 2940 nm mini-peels.

PATIENTS AND METHODS

Six female volunteers of Fitzpatrick skin type III-IV and Glogau's class I-III wrinkles were subjected to six microresurfacing peels at 2-week intervals using Er:YAG 2940 nm laser at subablative fluences of 2-3 J/cm(2) to treat periorbital rhytides. Quantitative evaluation of collagen types I, III, and VII, newly synthesized collagen, total elastin, and tropoelastin was performed by histochemistry and immunohistochemistry coupled with computerized morphometric analysis at base line, end of treatment, and 3 months post-treatment.

RESULTS

Compared to the base line, evaluation of volunteers revealed obvious clinical improvement in response to Er:YAG mini-peels. Collagen types I, III, and VII, as well as newly synthesized collagen, together with tropoelastin showed a statistically significant increase in response to treatment, while the mean level of total elastin was significantly decreased in response to treatment. However, this was followed by regression of improvement at 3 months post-treatment but was still better than baseline.

CONCLUSIONS

This study revealed that multiple Er:YAG mini-peels is a promising treatment option for photoaging as it reverses the signs of photoaged skin with little downtime and side effects. However, to maintain the short-term improvement achieved after treatment, continued Er:YAG 2940 nm laser mini-peels is required.

Random fractional ultrapulsed CO2 resurfacing of photodamaged facial skin: long-term evaluation

Although numerous papers have recently been published on ablative fractional resurfacing, there is a lack of information in literature on very long-term results. The aim of this retrospective study is to evaluate the efficacy, adverse side effects, and long-term results of a random fractional ultrapulsed CO2 laser on a large population with photodamaged facial skin. Three hundred twelve patients with facial photodamaged skin were enrolled and underwent a single full-face treatment. Six aspects of photodamaged skin were recorded using a 5 point scale at 3, 6, and 24 months after the treatment. The results were compared with a non-parametric statistical test, the Wilcoxon's exact test. Three hundred one patients completed the study. All analyzed features showed a significant statistical improvement 3 months after the procedure. Three months later all features, except for pigmentations, once again showed a significant statistical improvement. Results after 24 months were similar to those assessed 18 months before. No long-term or other serious complications were observed. From the significant number of patients analyzed, long-term results demonstrate not only how fractional ultrapulsed CO2 resurfacing can achieve good results on photodamaged facial skin but also how these results can be considered stable 2 years after the procedure.

Intraepidermal erbium:YAG laser resurfacing: impact on the dermal matrix

BACKGROUND

Various minimally invasive treatments enhance the skin's appearance. Little is known about the molecular mechanisms whereby treatments working at the epidermal level might alter the dermis.

OBJECTIVE

We sought to quantify the molecular changes that result from erbium:yttrium-aluminium-garnet (Er:YAG) laser microablative resurfacing.

METHODS

We performed biochemical analyses after intraepidermal Er:YAG laser resurfacing of 10 patients. Immunohistochemical analysis and polymerase chain reaction technology were utilized to measure key biomarkers.

RESULTS

The basement membrane remained intact after intraepidermal microablation, as demonstrated by laminin γ2 immunostaining. Epidermal injury was demonstrated with acute up-regulation of keratin 16. An inflammatory response ensued as indicated by increases in cytokines interleukin 1 beta (IL-1β) and IL-8 as well as a substantial neutrophil infiltrate. Levels of cJun and JunB proteins, components of the transcription factor AP-1 complex, were also elevated. Up-regulation of extracellular matrix degrading proteinases matrix metalloproteinase 1 (MMP-1), MMP-3, and MMP-9 was noted. A transient increase in keratinocyte proliferation, as indicated by staining for Ki67, was observed. Increased expression of type I and type III procollagen was demonstrated.

LIMITATIONS

The data presented are those that resulted from a single treatment session.

CONCLUSIONS

Although microablation was confined to the uppermost epidermis, marked changes in epidermal and dermal structure and function were demonstrated after Er:YAG laser microablative resurfacing. We demonstrated substantial dermal matrix remodeling, including a degree of collagen production that compares favorably with some more invasive interventions. Dermal remodeling and stimulation of collagen production are associated with wrinkle reduction. Thus these results suggest that the skin's appearance may be enhanced by creating dermal changes through the use of superficially acting treatments.

Low density, non-ablative fractional CO2 laser rejuvenation

BACKGROUND AND OBJECTIVES

Fractional skin rejuvenation has gained increased interest since its introduction in 2003. Both non-ablative and ablative lasers as well as different treatment techniques have been devised. Recent clinical studies indicate that a paradigm of low spot density combined with high fluences tend to produce better clinical results and less risk of post-inflammatory hyperpigmentation in darker skin types. The present study is focused on investigations of the clinical outcome by non-ablative fractional CO(2) treatments with a single pass with low spot density.

METHODS AND MATERIALS

A CO(2) laser was equipped with a scanner enabling it to perform fractional treatments with 36, 64 or 100 microthermal zones (MTZ)/cm(2). Twelve patients participated in the study. The perioral area was treated three times with 1-month intervals using a spot density of 64 MTZ/cm(2), a spot diameter of 0.5 mm, a micro-beam energy of 36-60 mJ, and a pulse duration of 3-5 milliseconds. Follow-up was performed 3 months after the last treatment.

RESULTS

At the 3-month follow-up 72.7% of the volunteers had obtained improvement in ultrasonographically determined dermal density, and the average improvement was 40.2% (SD: 48.0%). This improvement was statistically significant (P<0.006). Eighty percent of the volunteers rated the reduction in visible perioral wrinkles to be fair, good or excellent. For reduction of irregular pigmentation, fair, good or excellent clearance was reported by 62.5% of the volunteers.

CONCLUSIONS

The present study demonstrates subjective improvements in wrinkles, skin texture and mottled pigmentation as well as statistically significant objectively measured improvements in ultrasonographical dermal density after three non-ablative fractional CO(2) laser treatments.

Non-sequential fractional ultrapulsed CO2 resurfacing of photoaged facial skin: preliminary clinical report

This study evaluates results, adverse side effects and downtime of the protocol 'ActiveFX' for photodamaged facial skin. A non-sequential fractional ultrapulsed CO2 laser with specific settings is used in addition to a new computer pattern generator (CPG). From September 2006 to March 2007, 55 patients underwent this new 'soft' single-session, single-pass and full-face ablative fractional treatment. The patients were evaluated at baseline and 1 and 3 months after the treatment using a five-point scale. Seven aspects of photodamaged skin were recorded: global score, fine lines, mottled pigmentation, sallow complexion, tactile roughness, coarse wrinkles and telangiectasias. The results were compared with a non-parametric statistical test, the Wilcoxon's exact test. Eight patients received a double-pass treatment on the crow's feet regions and the improvement of the coarse wrinkles was analyzed with a quartile grading scale. Significant differences (p<0.05) between baseline and 1 and 3 months post-treatment were observed for all features except telangiectasias. Coarse wrinkles presented a good improvement only in the regions submitted to a double-pass. Minimal and isolated adverse side effects were noted and the downtime was very low. Non-sequential fractional ultrapulsed CO2 light treatment ('ActiveFX') can be considered an excellent alternative for photodamaged facial skin.