Nd:YAG laser combined with IPL treatment improves clinical results in non‐ablative photorejuvenation

Laser Resurfacing for the Management of Periorbital Scarring

Laser (light amplification by the stimulated emission of radiation) skin resurfacing is currently one of the most widely adopted technologies in facial rejuvenation. While most often used for aesthetic purposes, lasers also have applications in the management of scars. Since the introduction of the CO₂ laser for skin rejuvenation in the 1990s, the last three decades have seen significant growth in the number of laser devices available to the physician. More recently, promising alternatives to light-based resurfacing technologies have emerged that include radiofrequency and intense focused ultrasound. To help the physician navigate the most current laser technologies as they apply to periocular scars, this review discusses the available treatment modalities, pre-treatment assessment of periorbital scars, treatment selection, and reported outcomes and complications. The recommendations described herein are based on published literature and the authors' experience in an academic oculoplastics practice.

Sequential facial skin rejuvenation with intense pulsed light and non-ablative fractionated laser resurfacing in fitzpatrick skin type II-IV patients: A prospective multicenter analysis

Background

While skin aging is triggered by multiple factors and typically presents with multiple manifestations, conventional treatment regimens deploy a single treatment modality. Typical approaches exploit ablative techniques, which involve considerable patient discomfort and downtime and can induce adverse events. Non‐ablative fractionated laser (NAFL) resurfacing promotes neocollagenesis, with significantly fewer complications and discomfort. At the same time, intense pulsed light (IPL) therapies have a marked impact on skin tone, with an effect on collagen deposition. This study evaluated the combined effect of same‐day, sequential IPL‐NAFL treatment on photoaging of the face.

Design

In this prospective study, 30 patients presenting Fitzpatrick skin types II–IV, elastosis scores 3–6 and mild to moderate pigmentation, underwent three sessions, of full‐face IPL therapy, followed immediately by NAFL treatment, conducted at 4–6 weeks intervals. Wrinkle/elastosis and skin qualities were scored at 1, 3, and 6 months after the last treatment session. Immediate responses were evaluated up to 30 min following treatment and adverse events were monitored throughout the study period.

Results

Wrinkle/elastosis scores gradually improved over the treatment period, with 59% of patients presenting a ≥1‐point improvement in FES scores by the 1‐month follow‐up session, which persisted also at the 6 months follow‐up visit. Good to excellent pigmentation responses were recorded for ≥63% and improvements in texture, brightness, and tightness were recorded for ≥80% of patients throughout the follow‐up period. Over 90% of the treated patients exhibited improved or much improved overall appearance. Patient scorings and satisfaction level reflected physician assessments. Treatments were well tolerated and the social downtime observed was of 1.5 ± 0.25 days.

Conclusion

The same‐day combined IPL‐NAFL regimen proved safe and elicited a significant skin rejuvenating effect, in a similar manner to that shown in other same‐day combined therapies, without prolonging downtime of each individual modality. Lasers Surg. Med. 51:141–149, 2019. © 2018 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.

Broadband light treatment using static operation and constant motion techniques for skin tightening in Asian patients

BACKGROUND

Broadband light (BBL) devices irradiate photons of different wavelength to induce photothermal reactions on various aging-related chromophores.

OBJECTIVES

To evaluate three BBL treatment settings for skin tightening in Asian patients.

METHODS

A total of 27 patients underwent three sessions of BBL treatment via (1) an 800-nm cutoff filter using a static operation technique and a 695-nm cutoff filter using a constant motion technique (group 1, N = 9), (2) an 800-nm cutoff filter using a constant motion technique (group 2, N = 9), and (3) a 590-nm cutoff filter using a constant motion technique (group 3, N = 9).

RESULTS

The patients in group 1 presented marked clinical improvements in zygomatic wrinkles, nasolabial folds, and marionette lines, with a median overall global aesthetic improvement scale (GAIS) score of 3. Meanwhile, patients in group 2 exhibited noticeable improvements in zygomatic wrinkles, nasolabial folds, perioral expression wrinkles at the cheek, and marionette lines, with a median GAIS score of 3. Patients in group 3 experienced improvement in skin tone and texture, zygomatic wrinkles, nasolabial folds, and marionette lines, with a median GAIS score of 2.

CONCLUSIONS

Our data demonstrated that BBL treatment for nonablative, noninvasive skin tightening elicits satisfactory clinical outcomes.

Clinical Improvement of Photodamaged Skin after a Single Intense Pulsed Light Treatment

Background and Objectives:

Photoaging is clinically characterized by irregular pigmentation (freckling, lentigines, persistent hyperpigmentation), dryness/roughness, telangiectasia, wrinkling, elastosis, and inelasticity. Currently available medical literature documents using intense pulsed light (IPL) 3 to 5 times to achieve satisfactory improvement.

Study Design/Materials and Methods:

Twenty patients of Fitzpatrick skin types I–III, each with components of photodamaged skin including telangiectasias, dyschromia, skin roughness, enlarged pore size, and/or rhytides—participated in the study and were treated with a single Lumenis One IPL. Pretreatment and posttreatment photographs were graded by 2 independent physicians as to percent improvement.

Results:

After 1 treatment with the Lumenis One IPL, results showed an average improvement of 40% in resolving telangiectasias, dyspigmentation, and fine wrinkling.

Conclusions:

The present study demonstrates that as much as a 40% improvement in the overall appearance of photoaging can be obtained after a single treatment with the Lumenis One IPL. Previous studies with IPL using the Lumenis Photoderm, Vasculite, or Quantum systems found that 3 to 5 treatments were needed to obtain a similar improvement. These IPL systems have a smaller spot size, a different energy output profile, and a cutaneous cooling mechanism that may explain their decreased efficacy compared with the Lumenis One.

[Epidermal aging and anti-aging strategies]

Epithelial senescence is a complex process depending on intrinsic as well as extrinsic factors (e.g., UV or IR light, tobacco smoke) and must be seen in the context of the aging process especially of the corium and the subcutis. Morphological alterations become apparent in the form of epithelial atrophy, structural changes within the basal membrane, and a decrease in cell count of melanocytes and Langerhans cells. Signs of cellular senescence are reduced proliferation of keratinocytes, cumulation of dysplastic keratinocytes, various mutations (e.g., c-Fos/c-Jun, STAT3, FoxO1), as well as multiple lipid or amino acid metabolic aberrations (e.g., production of advanced glycation endproducts). This causes functional changes within the physical (lipid deficiency, water distribution dysfunction, lack of hygroscopic substances), chemical (pH conditions, oxygen radicals), and immunological barrier. Prophylactically, barrier-protective care products, antioxidant substances (e.g., vitamin C, B3, E, polyphenols, flavonoids), sunscreen products/measurements, and retinoids are used. For correcting alterations in aged epidermis, chemical peelings (fruit acids, β-hydroxy acid, trichloroacetic acid, phenolic compounds), non-ablative (IPL, PDL, Nd:YAG) as well as ablative (CO2, Erbium-YAG) light-assisted methods are used.

Comparison of effectiveness of 1,064-nm Nd:YAG laser and Nd:YAG laser-IPL combination treatments in hand skin rejuvenation

OBJECTIVE

Evaluation of the efficacy and side effects of neodymium-doped yttrium aluminum garnet (Nd:YAG) laser and Nd:YAG laser-intense pulsed light (IPL) combination treatments in photorejuvenations of skin of the hand, and determining their impacts on patient satisfaction.

MATERIALS AND METHODS

Thirty-five female patients with signs of photoaging on the skin of their hands were included in the study. Three sessions of IPL and four sessions of Nd:YAG laser treatment were applied to the right hand in total with 2-week intervals between each session, whereas six sessions of Nd:YAG laser treatment were applied to the left hand of patients with 2-week intervals between each session.

RESULTS

The patients' ages ranged between 31 and 78, and mean age was 60.77 ± 9.48. While there was no difference in pigment distribution, fine wrinkles, coarse wrinkles, and global scores between the right and left hand prior to treatment (p > 0.05), average pigment tone score was higher in the right hand with a statistically significant difference (p < 0.05). There was greater improvement in scores of pigment distribution, fine wrinkles, sallowness, pigment tone parameters, and global score on the right hand compared to left hand, which was statistically significant (p <0.001).

CONCLUSION

In rejuvenation of photoaged dorsal skin of the hand, IPL-Nd:YAG laser combination treatment surpasses Nd:YAG laser treatment.

Evaluation of procollagen I deposition after intense pulsed light treatments at varying parameters in a porcine model

Several lasers and light sources have been reported to induce dermal collagen remodeling without damaging the epidermis. The intense pulsed light (IPL) system, which emits polychromatic light of wavelengths between 560 and 1200 nm belongs to this group of increasingly popular non-ablative skin rejuvenation devices. Various IPL treatment parameters can be adjusted to achieve optimal dermal remodeling and clinical improvement. The aim of this study was to evaluate variations in IPL treatment parameters and the effect on procollagen I deposition. Marked areas of a live Yorkshire pig's flank skin were irradiated with a single or double pass of an IPL source using a fluence of 30 or 40 J/cm2 and a cut-off wavelength filter of 590 nm. Skin biopsies were performed on postoperative days 1, 7, 14, 21, and 42. A statistically significant increase in procollagen I in treated versus untreated sites was found on postoperative days 21 and 42, but not earlier. There was a uniformly significant increase in procollagen I on day 42 using the 590 nm filter at both 30 and 40 J/cm2 with either a single or double pass. The increase in procollagen was greater with a fluence of 40 J/cm2 compared with 30 J/cm2.

A possible mechanism for visible light-induced wound healing

BACKGROUND AND OBJECTIVES

Chronic wounds resistant to conventional therapy have been treated successfully with low energy lasers and light emitting diodes (LEDs) in the visible and near IR region. It has been proposed that production of low level reactive oxygen species (ROS) following illumination is the first step of photobiomodulation. It was also shown that white light (400-800 nm) has similar stimulatory effects as lasers and LEDs. ROS at higher levels are toxic to cells and bacteria.

STUDY DESIGN/MATERIALS AND METHODS

In the present study, we examined the phototoxicity of broadband (400-800 nm, 120 J/cm(2)) visible light on the survival of several pathogenic bacteria: Staphylococcus aureus 195, Pseudomonas aeruginosa 1316, Escherichia coli 1313, and Serratia marcescens. These bacteria were chosen due to their high prevalence in infected wounds. The survival of bacterial cells following illumination was monitored by counting the number of colony forming units before and after exposure to light.

RESULTS

Illumination with white light, 120 J/cm(2), caused a reduction of 62%, 83%, and 56% in the colony count of E. coli 1313, S. aureus 195 and S. marcescens, respectively, though no reduction in the viability of P. aeruginosa 1316 was demonstrated. The phototoxic effect was found to involve induction of ROS production by the bacteria. It was also found that illumination of S. aureus 195 and E. coli 1313 in the presence of pyocyanin, known to be secreted by P. aeruginosa, had a stronger bactericidal effect compared to illumination alone.

CONCLUSION

Visible light at high intensity can kill bacteria in infected wounds. Thus, illumination of infected wounds with intense visible light, prior to low intensity illumination for stimulating wound closure, may reduce infection and promote healing.

Nonablative 1,064-nm Nd:YAG laser for treating atrophic facial acne scars: histologic and clinical analysis

BACKGROUND

Non-ablative methods have been attempted in treating atrophic facial scars, but the histologic findings do not always coincide with the clinical results and patient satisfaction.

OBJECTIVE

To study the effects and safety of the Nd:YAG laser for treating atrophic facial scars.

MATERIAL AND METHODS

Twelve subjects (skin phototypes II-V) with mild to moderate atrophic facial acne scars received five monthly treatments with 1,064 nm Nd:YAG laser and were photographed before, in the middle of, and 6 months after the last treatment. Histologic evaluations were performed on skin biopsies obtained before treatment and 1 month after the last session. Collagen quantification per area, before and after the treatment, was performed by morphometry, with computerized image analysis. Patient satisfaction and clinical condition were assessed using standard grading scales.

RESULTS

Mild to moderate clinical improvement was observed in most patients. Photographic assessment of scars found visible cosmetic improvement in eleven patients. All patients were satisfied. There were statistically significant collagen increases in the dermis following the treatment. Side effects were limited to mild transient erythema and increased skin sensitivity after the procedure.

CONCLUSIONS

The 1,064 nm Nd:YAG laser is a safe and effective nonablative method for improving atrophic scars, even in darker skin.

Facial rejuvenation and light: our personal experience

The treatment of ageing skin remains a very hot topic, and many systems have been reported as having varying degrees of success. Nonablative lasers were developed to avoid the problematic and uncomfortable sequelae following laser ablative resurfacing, and while there was no downtime, there was also poor patient satisfaction. The same was true of the intense pulsed light systems. The use of different modalities in various combinations was found to offer much better results, however, such as a 595-nm pulsed dye laser followed by a 1,450-nm diode laser, and so on, all used at subablative thresholds. The recent entry of blue and infrared tunable plasma light and light-emitting diodes into the skin rejuvenation arena has attracted a great deal of attention. The authors suggest that no single modality can accomplish all the complex events required for effective skin rejuvenation, suggest that combination phototherapy is the best approach combined with an adjunctive epidermal care regimen, and demonstrate their development of this methodology.

Carcinogenesis related to intense pulsed light and UV exposure: an experimental animal study

This study examines whether intense pulsed light (IPL) treatment has a carcinogenic potential itself or may influence ultraviolet (UV)-induced carcinogenesis. Secondly, it evaluates whether UV exposure may influence IPL-induced side effects. Hairless, lightly pigmented mice (n=144) received three IPL treatments at 2-week intervals. Simulated solar radiation was administered preoperatively [six standard erythema doses (SED) four times weekly for 11 weeks] as well as pre- and postoperatively (six SED four times weekly up to 26 weeks). Skin tumors were assessed weekly during a 12-month observation period. Side effects were evaluated clinically. No tumors appeared in untreated control mice or in just IPL-treated mice. Skin tumors developed in UV-exposed mice independently of IPL treatments. The time it took for 50% of the mice to first develop skin tumor ranged from 47 to 49 weeks in preoperative UV-exposed mice (p=0.94) and from 22 to 23 weeks in pre- and postoperative UV-exposed mice (p=0.11). IPL rejuvenation of lightly pigmented skin did not induce pigmentary changes (p=1.00). IPL rejuvenation of UV-pigmented skin resulted in an immediate increased skin pigmentation and a subsequent short-term reduced skin pigmentation (p<0.002). Postoperative UV radiation resulted in re-pigmentation of IPL-induced pigment reduction (p=0.12). No texture changes were observed. Postoperative edema and erythema were increased by preoperative UV exposure (p<0.002). IPL rejuvenation has no carcinogenic potential itself and does not influence UV-induced carcinogenesis. UV exposure influences the occurrence of side effects after IPL rejuvenation in an animal model.

Phototherapy in anti-aging and its photobiologic basics: a new approach to skin rejuvenation

Intrinsic aging and photoaging of the face are constantly ongoing, and eventually result in the typical "aged" face, with visible lines and wrinkles at rest, a variety of dyschromia and a tired, dull and lax epidermis over poorly organized elastotic dermal architecture characterized by many interfibrillary spaces. Both ablative and nonablative resurfacing have been reported as solutions, the former providing excellent results, but a long patient downtime, and the latter giving little or no downtime, but less-than-ideal results. In ablative resurfacing, the epidermis is removed and replaced with a "new" epidermis, whereas in the nonablative approach the epidermis is spared through some form of cooling. In both approaches, however, the goal is to create controlled amounts of thermal damage in the dermis to stimulate the wound healing process, thus generating a tighter, better organized, "younger" dermal matrix. A better approach might be to apply prevention, rather than the cure, and to treat subjects in their very early 20s, before even fine lines have begun to appear. This "photoanti-aging" approach could be achieved with the use of very low incident levels of photon energy to stimulate the skin cells, both epidermal and dermal, at cell-specific wavelengths based on the photobiological findings of the literature over the past two decades or so, in order to increase their resistance to the effects of chronological and photoaging. Lasers and IPL systems could be used, but are extremely expensive and therapist-intensive. A new generation of light-emitting diodes (LEDs) has appeared as the result of a spin-off from the US NASA Space Medicine Program, which are much more powerful than the previous generation with quasimonochromatic outputs. These LEDs can offer target specificity to achieve photobiomodulated enhanced action potentials of the skin cells, in particular mast cells, macrophages, endotheliocytes, and fibroblasts, plus increases in local blood and lymphatic flow, in a noninvasive, athermal manner. New phototherapeutic LED-based systems have appeared to meet the need for a less-expensive but clinically useful light source to enable photoantiaging as a reality in clinical practice. Some studies proving the efficacy of LED therapy have already appeared, and based on their results LED therapy represents a potential new approach to prevention in anti-aging, so that further studies are warranted to prove its efficacy.

Ablative versus non-ablative treatment of perioral rhytides. A randomized controlled trial with long-term blinded clinical evaluations and non-invasive measurements

BACKGROUND AND OBJECTIVE

To compare efficacy and side effects of CO(2) laser resurfacing and intense pulsed light (IPL) rejuvenation for treatment of perioral rhytides.

METHODS

Twenty-seven female subjects with perioral rhytides (class I-III) were randomly treated with either CO(2) laser or IPL (three monthly treatments). Efficacy was evaluated by patient self-assessments and blinded photographs up to 12 months postoperatively. Side effects were assessed clinically. Non-invasive measurements included: trans epidermal water loss (TEWL), skin reflectance, skin elasticity, and ultrasound.

RESULTS

CO(2) laser resurfacing resulted in higher degrees of patient satisfaction and clinical rhytide reduction compared to IPL rejuvenation up to 12 months postoperatively (patient evaluations, P < 0.05) (observer evaluations, P < 0.008). Laser-induced side effects included erythema, dyspigmentation, and milia whereas no side effects were observed after IPL rejuvenation. Non-invasive measurements showed a significant higher reduction of the subepidermal low-echogenic band in CO(2) laser treated areas versus IPL treated areas (12 months postoperatively, P < 0.001). Skin elasticity (expressed as Young's modulus) increased in both groups (P = ns). One month postoperatively a significant increase in TEWL values (P < 0.009) and skin redness% (P < 0.02) was found in CO(2) laser treated patients versus IPL treated patients. No significant differences were seen in skin pigmentation% during the observation period.

CONCLUSION

CO(2) laser resurfacing induces a significantly higher degree of clinical rhytide reduction followed by considerably more side effects compared to IPL rejuvenation in a homogeneous group of patients.