Fractionation: A New Era in Laser Resurfacing

Dermal Fibroblasts as the Main Target for Skin Anti-Age Correction Using a Combination of Regenerative Medicine Methods

This article includes the data from current studies regarding the pathophysiological mechanisms of skin aging and the regenerative processes occurring in the epidermis and dermis at the molecular and cellular level, mainly, the key role of dermal fibroblasts in skin regeneration. Analyzing these data, the authors proposed the concept of skin anti-age therapy that is based on the correction of age-related skin changes by stimulating regenerative processes at the molecular and cellular level. The main target of the skin anti-age therapy is dermal fibroblasts (DFs). A variant of the cosmetological anti-age program using the combination of laser and cellular methods of regenerative medicine is presented in the paper. The program includes three stages of implementation and defines the tasks and methods of each stage. Thus, laser technologies allow one to remodel the collagen matrix and create favorable conditions for DFs functions, whereas the cultivated autologous dermal fibroblasts replenish the pool of mature DFs decreasing with age and are responsible for the synthesis of components of the dermal extracellular matrix. Finally, the use of autological platelet-rich plasma (PRP) enables to maintenance of the achieved results by stimulating DF function. It has been shown that growth factors/cytokines contained in α-granules of platelets injected into the skin bind to the corresponding transmembrane receptors on the surface of DFs and stimulate their synthetic activity. Thus, the consecutive, step-by-step application of the described methods of regenerative medicine amplifies the effect on the molecular and cellular aging processes and thereby allows one to optimize and prolong the clinical results of skin rejuvenation.

Fractional Ablative Carbon Dioxide Lasers for the Treatment of Morphea: A Case Series and Literature Review

Morphea is an inflammatory, immune-mediated disease of unknown aetiology. It is characterised by excessive collagen deposition, which leads to the hardening of the dermis and subcutaneous tissues. The disease is associated with cosmetic and functional impairment, which can affect the patients’ quality of life. Fractional ablative lasers (FALs) are currently used for the treatment of many skin diseases that are connected to tissue fibrosis due to the low risk of side effects and their great effectiveness. This study aimed to improve the aesthetic defects that are caused by morphea lesions and assess the efficacy and safety of FAL use in this indication. We also reviewed the literature on the subject. We present four women with biopsy-proven morphea, manifesting as hyperpigmented plaques and patches. One of the patients additionally had morphea-related knee joint contracture. Four fractional CO2 laser sessions, separated by one-month intervals, were performed and produced significant improvements in dyspigmentation and induration. An improved elasticity and a decrease in dermal thickness were also obtained, as proven by measurements using DermaLab Combo. No severe adverse effects occurred. Based on these cases presented by the authors, fractional CO2 lasers appear to be an effective, well-tolerated, and safe therapeutic option for patients suffering from morphea.

Laser vaccine adjuvants: Light-augmented immune responses

Adjuvants are essential for ensuring the efficacy of modern vaccines. Considering frequent local and systemic adverse reactions, research into the development of safer and more effective adjuvants is being actively conducted. In recent years, the novel concept of laser vaccine adjuvants, which use the physical energy of light, has been developed. For long, light has been known to affect the physiological functions in living organisms. Since the development of lasers as stable light sources, laser adjuvants have evolved explosively in multiple ways over recent decades. Future laser adjuvants would have the potential not only to enhance the efficacy of conventional vaccine preparations but also to salvage candidate vaccines abandoned during development because of insufficient immunogenicity or owing to their inability to be combined with conventional adjuvants. Furthermore, the safety and efficacy of non-invasive laser adjuvants make them advantageous for vaccine dose sparing, which would be favorable for the timely and equitable global distribution of vaccines. In this review, we first describe the basics of light-tissue interactions, and then summarize the classification of lasers, the history of laser adjuvants, and the mechanisms by which different lasers elicit an immune response.

Innovative Systems to Deliver Allergen Powder for Epicutaneous Immunotherapy

Allergy is a disorder owing to hyperimmune responses to a particular kind of substance like food and the disease remains a serious healthcare burden worldwide. This unpleasant and sometimes fatal allergic disease has been tackled vigorously by allergen-specific immunotherapy over a century, but the progress made so far is far from satisfactory for some allergies. Herein, we introduce innovative, allergen powder-based epicutaneous immunotherapies (EPIT), which could potentially serve to generate a new stream of technological possibilities that embrace the features of super safety and efficacious immunotherapy by manipulating the plasticity of the skin immune system via sufficient delivery of not only allergens but also tolerogenic adjuvants. We attempt to lay a framework to help understand immune physiology of the skin, epicutaneous delivery of powdered allergy, and potentials for tolerogenic adjuvants. Preclinical and clinical data are reviewed showing that deposition of allergen powder into an array of micropores in the epidermis can confer significant advantages over intradermal or subcutaneous injection of aqueous allergens or other epicutaneous delivery systems to induce immunological responses toward tolerance at little risk of anaphylaxis. Finally, the safety, cost-effectiveness, and acceptability of these novel EPITs are discussed, which offers the perspective of future immunotherapies with all desirable features.

Plume Effect of Fractional Radiofrequency Verus Laser Resurfacing: Considerations in the COVID-19 Pandemic

INTRODUCTION

The COVID-19 pandemic requires us all to re-evaluate aesthetic practices to ensure optimal patient safety during elective procedures. Specifically, energy-based devices and lasers require special consideration, as they may emit plume which has been shown to contain tissue debris and aerosolized biological materials. Prior studies have shown transmission of viruses and bacteria via plume (i.e., HIV and papillomavirus). The purpose of this study was to evaluate plume characteristics of the Er:YAG resurfacing laser (Sciton; Palo Alto, CA) and compare it to the Morpheus8 fractional radiofrequency device (InMode; Lake Forest, CA).

METHODS

Five patients who underwent aesthetic resurfacing and/or skin tightening of the face and neck were treated with the Er:YAG (Sciton Joule, Palo Alto, CA) and/or fractional radiofrequency (Morpheus8, Lake Forest, CA) between April 1 and May 11, 2020. Data collected included patient demographics, past medical history, treatment parameters, adverse events, particle counter data, as well as high magnification video equiptment. Patients were evaluated during treatment with a calibrated particle meter (PCE; Jupiter, FL). The particle meter was used at a consistent focal distance (6-12 inches) to sample the surrounding environment during treatment at 2.83 L/min to a counting efficiency of 50% at 0.3 µm and 100% at >0.45 µm. Recordings were obtained with and without a smoke evacuator.

RESULTS

Of our cohort (n = 5), average age was 58 years old (STD ±7.2). Average Fitzpatrick type was between 2 and 3. Two patients received Er:YAG fractional resurfacing in addition to fractional radiofrequency during the same treatment session. Two patients had fractional radiofrequency only, and one patient had laser treatment with the Er:YAG only. There were no adverse events recorded. The particle counter demonstrated ambient baseline particles/second (pps) at 8 (STD ±6). During fractional radiofrequency treatment at 1-mm depth, the mean recording was 8 pps (STD ±8). At the more superficial depth of 0.5 mm, recordings showed 10 pps (STD ±6). The Er:YAG laser resurfacing laser had mean readings of 44 pps (STD ±11). When the particle sizes were broken down by size, the fractional radiofrequency device had overall smaller particle sizes with a count of 251 for 0.3 µm (STD ±147) compared with Er:YAG laser with a count of 112 for 0.3 µm (STD ±84). The fractional radiofrequency did not appear to emit particles >5 µm throughout the treatment, however, the Er:YAG laser consistently recorded majority of particles in the range of 5-10 µm. The addition of the smoke evacuator demonstrated a 50% reduction in both particles per second recorded as well as all particle sizes.

CONCLUSION

Re-evaluation of the plume effect from aesthetic devices has become important during the COVID-19 pandemic. Further studies are required to characterize viability of COVID-19 viability and transmissibility in plume specimens. Based on this pilot study, we recommend that devices that generate little to no plume such as fractional radiofrequency devices be used in Phase I reopening of practice while devices that generate a visible plume such as Er:YAG laser resurfacing devices be avoided and only used with appropriate personal protective equipment in addition to a smoke evacuator in Phase IV reopening.

A meta-analysis of fractional CO2 laser combined with PRP in the treatment of acne scar

This study aimed to analyze the effectiveness and safety of ablative fractional carbon dioxide laser systems (CO₂ AFL) combined with autologous platelet-rich plasma (PRP) in the treatment of acne scars through the retrieval and collection of related literature to further guide the treatment of acne scars. We searched Web of Science, PubMed, Embase, Wanfang Data, Chinese National Knowledge Infrastructure, and VIP Database. All randomized and nonrandomized controlled trials on CO₂ AFL combined with PRP in the treatment of acne scars were included, and Revman5.3 systematic review software was used in the meta-analysis. Nine studies were included in this meta-analysis. The data analysis results showed that the CO₂ AFL combined with PRP treatment group showed significantly better results than the pure CO₂ AFL control group in terms of clinical improvement score, clinical improvement rate, patient satisfaction, and crusting period. The results of this meta-analysis showed that CO₂ AFL combined with PRP in the treatment of acne scars is more effective and safer than CO₂ AFL alone.

Laser adjuvant for vaccination

The use of an immunologic adjuvant to augment the immune response is essential for modern vaccines which are relatively ineffective on their own. In the past decade, researchers have been consistently reporting that skin treatment with a physical parameter, namely laser light, augments the immune response to vaccine and functions as an immunologic adjuvant. This "laser adjuvant" has numerous advantages over the conventional chemical or biological agents; it is free from cold chain storage, hypodermic needles, biohazardous sharp waste, irreversible formulation with vaccine antigen, undesirable biodistribution in vital organs, or unknown long-term toxicity. Since vaccine formulations are given to healthy populations, these characteristics render the "laser adjuvant" significant advantages for clinical use and open a new developmental path for a safe and effective vaccine. In addition, laser technology has been used in the clinic for more than three decades and is therefore technically matured and has been proved to be safe. Currently, four classes of laser adjuvant have been reported; ultrashort pulsed, non-pulsed, non-ablative fractional, and ablative fractional lasers. Since each class of the laser adjuvant shows a distinct mechanism of action, a proper choice is necessary to craft an effective vaccine formulation toward a desired clinical benefit for a clinical vaccine to maximize protection. In addition, data also suggest that further improvement in the efficacy is possible when a laser adjuvant is combined with chemical or biological adjuvant(s). To realize these goals, further efforts to uncover the molecular mechanisms of action of the laser adjuvants is warranted. This review provides a summary and comments of the recent updates in the laser adjuvant technology.

Posttraumatic Laser Treatment of Soft Tissue Injury

Laser treatment for posttraumatic injury offers the clinician the unique opportunity for early intervention in mediating early scar formation, or for reducing the appearance of scars after maturation. In this review, the authors focus on the mechanisms by which lasers exert their therapeutic effects, highlighting several popular lasers and dosimetry used, and underscoring the power of combined surgical scar revision in managing posttraumatic facial scars.

Fractional carbon dioxide laser for the treatment of facial atrophic acne scars: prospective clinical trial with short and long-term evaluation

The aim of this study was to evaluate the efficacy and safety of fractional carbon dioxide laser for the treatment of acne scars. Thirty-one participants, 15 female and 16 male, whose mean age was 34.84 ± 10.94 years, were included in this prospective study. The study took place between 2012 and 2016. Participants were evaluated with the "ECCA Grading Scale" before the first session, 3 months (short-term evaluation) and 3 years after the last session (long-term evaluation). Participants received two or three treatment sessions at 4-week intervals, with a 10,600 nm fractional carbon dioxide laser with pulse energies ranging between 100 and 160 mJ, 120 spot type, 75-100 spot/cm² density, and 30 W power. Self-assessments by the participants were done 3 months and 3 years after the last session. The mean ECCA score was 107.90 ± 39.38 before the first session, and 82.17 ± 36.23 at the time of short-term evaluation (p = 0.000). The grade of improvement at the short-term evaluation was as follows: no improvement, mild, moderate, and significant improvement for 7 (22.6%), 11 (35.5%), 9 (29%), and 4 (12.9%) of the participants, respectively. Regarding self-assessments, 80.6 and 61.3% of the participants rated themselves as having at least mild improvement at the short-term and the long-term follow-up periods, respectively. The results of this study suggest that fractional carbon dioxide laser is an efficient treatment option for acne scars. Furthermore, self-assessment results show that more than half of the participants still experience at least mild improvement at the end of 3 years.

Reconstitution of full-thickness skin by microcolumn grafting

In addition to providing a physical barrier, skin also serves a diverse range of physiological functions through different specialized resident cell types/structures, including melanocytes (pigmentation and protection against ultraviolet radiation), Langerhans cells (adaptive immunity), fibroblasts (maintaining extracellular matrix, paracrine regulation of keratinocytes), sweat glands (thermoregulation) and hair follicles (hair growth, sensation and a stem cell reservoir). Restoration of these functional elements has been a long-standing challenge in efforts to engineer skin tissue, while autologous skin grafting is limited by the scarcity of donor site skin and morbidity caused by skin harvesting. We demonstrate an alternative approach of harvesting and then implanting μm-scale, full-thickness columns of human skin tissue, which can be removed from a donor site with minimal morbidity and no scarring. Fresh human skin microcolumns were used to reconstitute skin in wounds on immunodeficient mice. The restored skin recapitulated many key features of normal human skin tissue, including epidermal architecture, diverse skin cell populations, adnexal structures and sweat production in response to cholinergic stimulation. These promising preclinical results suggest that harvesting and grafting of microcolumns may be useful for reconstituting fully functional skin in human wounds, without donor site morbidity. © 2016 The Authors Journal of Tissue Engineering and Regenerative Medicine Published by John Wiley & Sons Ltd.

Minimally Invasive Radiofrequency Devices

This article reviews minimally invasive radiofrequency options for skin tightening, focusing on describing their mechanism of action and clinical profile in terms of safety and efficacy and presenting peer-reviewed articles associated with the specific technologies. Treatments offered by minimally invasive radiofrequency devices (fractional, microneedling, temperature-controlled) are increasing in popularity due to the dramatic effects they can have without requiring skin excision, downtime, or even extreme financial burden from the patient's perspective. Clinical applications thus far have yielded impressive results in treating signs of the aging face and neck, either as stand-alone or as postoperative maintenance treatments.

Treatment of atrophic facial acne scars with fractional Er:YAG laser in skin phototype III-IV: A pilot study

BACKGROUND

Fractional ablative lasers have recently been used for the treatment of skin scars. The objective of this study was to assess the efficacy and safety of the fractional erbium-doped yttrium aluminum garnet (Er:YAG) laser (2940 nm) in the treatment of skin scars.

MATERIALS AND METHODS

A total of 9 patients (8 female, 1 male) with Fitzpatrick skin types III and IV suffering from atrophic facial acne scars were treated with a fractional Er:YAG laser for 2-5 (mean 3.3) sessions 4-6 weeks apart. One independent investigator assessed the efficacy, using standardized photographs, before and 1 month after the last treatment. The patients' satisfaction rate was also evaluated.

RESULTS

The treatment was well tolerated by all patients without any anesthesia. The downtime was 2-3 days. All patients showed improvement in scars: excellent in 1, good in 1, and fair in 7 patients. Six patients were highly satisfied and 3 were satisfied with treatment. No adverse effect was noted.

CONCLUSION

A fractional Er:YAG laser can deliver an effective and minimally invasive treatment for acne scars.

Classification of Laser Vaccine Adjuvants

An immunologic adjuvant, which enhances the magnitude and quality of immune responses to vaccine antigens, has become an essential part of modern vaccine practice. Chemicals and biologicals have been typically used for this purpose, but there are an increasing number of studies that are being conducted on the vaccine adjuvant effect of laser light on the skin. Currently, four different types or classes of laser devices have been shown to systemically enhance immune responses to intradermal vaccination: ultra-short pulsed lasers, non-pulsed lasers, non-ablative fractional lasers and ablative fractional lasers. Aside from involving the application of laser light to the skin in a manner that minimizes discomfort and damage, each type of laser vaccine adjuvant involves emission parameters, modes of action and immunologic adjuvant effects that are quite distinct from each other. This review provides a summary of the four major classes of “laser vaccine adjuvant” and clarifies and resolves their characteristics as immunologic adjuvants. These aspects of each adjuvant’s properties will ultimately help define which laser would be most efficacious in delivering a specific clinical benefit with a specific vaccine.

Laser Resurfacing for Latin Skins: The Experience with 665 Cases

BACKGROUND

CO2 resurfacing and CO2 microfractionated laser systems are reliable tools to improve different facial pathologic skin conditions but are associated with a high rate of complications specially in Fitzpatrick III, IV, and V skin phototypes, predominant in the Latin population, which has pushed many surgeons to change technologies and abandon its use.

OBJECTIVE

To compare patient results with the CO2 resurfacing laser and microfractionated CO2 laser resurfacing in all skin types and show similar results to those obtained worldwide in patients with phototypes III, IV, and V.

METHODS

Standardized review of medical records from a database of private practice patients treated since January 1998 to July 2012 with SlimE30 MiXto SX(®) CO2 laser. Evaluation of outcomes, complications, and satisfaction of three different modalities of treatment (CO2 ablative laser, CO2 microfractionated and a combination of both) was made.

RESULTS

A total of 665 treated patients were included. Ablative CO2 was applied to 80.3 %, CO2 microfractionated to 15.1 %, and mixed treatment to 4.5 % of cases. Globally, hyperpigmentation rates were 30.4 % in the CO2 resurfacing group, 16.3 % when a combination of modalities was applied and 11 % in microfractionated CO2 cases. A steady increase of these rates is shown as the phototype becomes higher. Satisfaction rates were high for all groups: 86.7 % in the mixed group, 82.2 % in the microfractionated CO2, and 79.6 % in the CO2 ablative.

CONCLUSIONS

Good results and an acceptable rate of complications in latin skins are obtainable after treating patients with CO2 ablative and microfractionated CO2 systems alone or in combination. Staged treatments and adequate post-procedure care reduce these complications.

Skin resurfacing procedures: new and emerging options

The demand for skin resurfacing and rejuvenating procedures has progressively increased in the last decade and has sparked several advances within the skin resurfacing field that promote faster healing while minimizing downtime and side effects for patients. Several technological and procedural skin resurfacing developments are being integrated into clinical practices today allowing clinicians to treat a broader range of patients' skin types and pathologies than in years past, with noteworthy outcomes. This article will discuss some emerging and developing resurfacing therapies and treatments that are present today and soon to be available.

A micro-sterile inflammation array as an adjuvant for influenza vaccines

There is an urgent need of adjuvants for cutaneous vaccination. Here we report that micro-sterile inflammation induced at inoculation sites can augment immune responses to influenza vaccines in animal models. The inoculation site is briefly illuminated with a handheld, non-ablative fractional laser before the vaccine is intradermally administered, which creates an array of self-healing microthermal zones (MTZs) in the skin. The dying cells in the MTZs send “danger” signals that attract a large number of antigen-presenting cells, in particular, plasmacytoid dendritic cells (pDCs) around each MTZ forming a micro-sterile inflammation array. A pivotal role for pDCs in the adjuvanticity is ascertained by significant abrogation of the immunity after systemic depletion of pDCs, local application of a TNF-α inhibitor, or null mutation of IFN regulatory factor7 (IRF7). In contrast to conventional adjuvants that cause persistent inflammation and skin lesions, micro-sterile inflammation enhances efficacy of influenza vaccines, yet with diminished adverse effects.

An update on the use of laser technology in skin vaccination

Vaccination via skin often induces stronger immune responses than via muscle. This, in line with potential needle-free, painless delivery, makes skin a very attractive site for immunization. Yet, despite decades of effort, effective skin delivery is still in its infant stage and safe and potent adjuvants for skin vaccination remain largely undefined. We have shown that laser technologies including both fractional and non-fractional lasers can greatly augment vaccine-induced immune response without incurring any significant local and systemic side effects. Laser illumination at specific settings can accelerate the motility of antigen-presenting cells or trigger release of 'danger' signals stimulating the immune system. Moreover, several other groups including the authors explore laser technologies for needle-free transcutaneous vaccine delivery. As these laser-mediated resurfacing technologies are convenient, safe and cost-effective, their new applications in vaccination warrant clinical studies in the very near future.

Fractional Skin Harvesting: Autologous Skin Grafting without Donor-site Morbidity

Background:

Conventional autologous skin grafts are associated with significant donor-site morbidity. This study was conducted to determine feasibility, safety, and efficacy of a new strategy for skin grafting based on harvesting small columns of full-thickness skin with minimal donor-site morbidity.

Methods:

The swine model was used for this study. Hundreds of full-thickness columns of skin tissue (~700 µm diameter) were harvested using a custom-made harvesting device, and then applied directly to excisional skin wounds. Healing in donor and graft sites was evaluated over 3 months by digital photographic measurement of wound size and blinded, computer-aided evaluation of histological features and compared with control wounds that healed by secondary intention or with conventional split-thickness skin grafts (STSG).

Results:

After harvesting hundreds of skin columns, the donor sites healed rapidly without scarring. These sites reepithelialized within days and were grossly and histologically indistinguishable from normal skin within 7 weeks. By contrast, STSG donor sites required 2 weeks for reepithelialization and retained scar-like characteristics in epidermal and dermal architecture throughout the experiment. Wounds grafted with skin columns resulted in accelerated reepithelialization compared with ungrafted wounds while avoiding the “fish-net” patterning caused by STSG.

Conclusion:

Full-thickness columns of skin can be harvested in large quantities with negligible long-term donor-site morbidity, and these columns can be applied directly to skin wounds to enhance wound healing.

Use of 1540nm fractionated erbium:glass laser for split skin graft resurfacing: a case study

The field of laser skin resurfacing has evolved rapidly over the past two decades from ablative lasers, to nonablative systems using near-infrared, intense-pulsed light and radio-frequency systems, and most recently fractional laser resurfacing. Although fractional thermolysis is still in its infancy, its efficacy in in the treatment of skin disorders have been clearly demonstrated. Here we present a case report on the safety and efficacy of a 1540nm erbium:glass laser in the treatment of the waffle pattern of a meshed skin graft in a 38-year-old patient with type V skin in the Caribbean.

Fractionation: past, present, future

The development of fractional photothermolysis is a milestone in the history of laser technology and cutaneous resurfacing. Based on the concept that skin is treated in a fractional manner, where narrow cylinders of tissue are thermally heated and normal adjacent skin is left unaffected, the fractional devices have shown effectiveness in treating a variety of conditions. Since its development, we are becoming more adept at using optimal parameters to induce near carbon dioxide laser benefits with a much more comfortable postoperative period and fewer complications. The future remains bright for fractionated laser devices and with new devices and wavelengths, the applications of this technology continue to grow.

Aesthetic surgery of the orbits and eyelids

This article discusses the relevant anatomy, the aging process of the eyelid with periorbital structure, and how to evaluate patients for a proper surgical approach. A description is given of how to achieve an aesthetic balance between the forehead, eyelids, and midface to provide the patient with a natural youthful appearance. The paradigm in oculoplastic surgery has shifted to more conservative eyelid skin, muscle, and fat resection as well as more periorbital soft tissue lift, suspension, and volumization. Recent innovations and developments are discussed as well as the most common complications in eyelid and periorbital surgery.