Nonablative laser treatment of wrinkles: meeting the objective? Assessment by 25 dermatologists

Nonablative laser skin resurfacing for periorbital wrinkling-A case series of 16 patients

BACKGROUND

Many modalities have been described for the treatment of periorbital wrinkling.

AIMS

The purpose of this study is to quantify the improvement of periorbital wrinkling achieved by current nonablative modalities, using a fractional 1565 nm Er:glass fiber laser.

METHODS

Our study is a retrospective two-center case series including 16 patients treated with nonablative laser for periorbital wrinkling at the Tel-Aviv Sourasky Medical Center in Israel and Laserplast Aesthetic Medicine Center in Italy between 2017 and 2019. Patients were assessed for objective and subjective improvement, patient satisfaction, side effect profile, and downtime.

RESULTS

Improvement in average Fitzpatrick Wrinkle Scale scores (from 4.3 to 2.7 by ranking physician 1 and 3.8 to 2.4 by ranking physician 2, P < .001) was observed after 8 weeks. Global Assessment Improvement Scale scores were 2.6 (physician 1) and 2.2 (physician 2) on average. This correlated to mild-moderate subjective sense of improvement by patients. Side effects and downtime were minimal.

CONCLUSION

Our study suggests that current nonablative laser skin resurfacing technology offers a mild-moderate improvement in periorbital wrinkling.

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.

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.

Ablative fractional lasers (CO(2) and Er:YAG): a randomized controlled double-blind split-face trial of the treatment of peri-orbital rhytides

BACKGROUND AND OBJECTIVE

Ablative fractional lasers were introduced for treating facial rhytides in an attempt to achieve results comparable to traditional ablative resurfacing but with fewer side effects. However, there is conflicting evidence on how well this goal has generally been achieved as well as on the comparative value of fractional CO(2) and Er:YAG lasers. The present study compares these modalities in a randomized controlled double-blind split-face study design.

STUDY DESIGN/MATERIALS AND METHODS

Twenty-eight patients were enrolled and completed the entire study. Patients were randomly assigned to receive a single treatment on each side of the peri-orbital region, one with a fractional CO(2) and one with a fractional Er:YAG laser. The evaluation included the profilometric measurement of wrinkle depth, the Fitzpatrick wrinkle score (both before and 3 months after treatment) as well as the assessment of side effects and patient satisfaction (1, 3, 6 days and 3 months after treatment).

RESULTS

Both modalities showed a roughly equivalent effect. Wrinkle depth and Fitzpatrick score were reduced by approximately 20% and 10%, respectively, with no appreciable difference between lasers. Side effects and discomfort were slightly more pronounced after Er:YAG treatment in the first few days, but in the later course there were more complaints following CO(2) laser treatment. Patient satisfaction was fair and the majority of patients would have undergone the treatment again without a clear preference for either method.

CONCLUSIONS

According to the present study, a single ablative fractional treatment session has an appreciable yet limited effect on peri-orbital rhytides. When fractional CO(2) and Er:YAG lasers are used in such a manner that there are comparable post-operative healing periods, comparable cosmetic improvement occurs. Multiple sessions may be required for full effect, which cancels out the proposed advantage of fractional methods, that is, fewer side effects and less down time.

The modified Fitzpatrick Wrinkle Scale: a clinical validated measurement tool for nasolabial wrinkle severity assessment

BACKGROUND

The number of existing wrinkle assessment scales makes it difficult to compare the efficacy of cosmetic techniques in rejuvenating photoaged skin. A single and simple assessment scale that reliably quantifies wrinkle depth is needed.

OBJECTIVE

The objective was to validate the Modified Fitzpatrick Wrinkle Scale (MFWS) as a nasolabial wrinkle severity assessment tool.

METHODS AND MATERIALS

The MFWS comprises three main classes, in which definitions are based on a set of reference photographs and descriptions, and three interclasses, in which definitions are based only on descriptions. Assessors were trained to apply this scale to volunteers and study patients by using photographs of nasolabial wrinkles either alone or with descriptions. Inter- and intraassessment reliability coefficients were calculated using weighted kappa statistics.

RESULTS

In patients, the combined intraassessor reliability from both sides of the face was 0.71 (95% confidence interval [CI], 0.68-0.74) when only photographs were used and 0.79 (95% CI, 0.76-0.82) when descriptions were added. Interassessor reliability for the photographs alone was 0.65 (95% CI, 0.62-0.68) and 0.74 (95% CI, 0.69-0.79) for photographs plus descriptions.

CONCLUSIONS

The MFWS is a reliable method for quantitative assessment of nasolabial skin folds, with good inter- and intraassessor reliability. Including descriptions with the photographs increased reliability.

Nonablative tissue remodeling and photorejuvenation

Nonablative facial resurfacing is a noninvasive approach to tissue remodeling and skin rejuvenation. These procedures are considered an alternative to the more traditional laser resurfacing with less dramatic effects, but also with significantly less downtime. Results vary based on the lasers and light sources used. In general, the infrared lasers improve texture, visible light lasers somewhat improve texture but greatly reduce redness and telangiectasias, and intense pulsed light devices improve both red targets and brown discoloration, as well as skin texture. Lastly, low-energy devices may improve redness and texture modestly. Patient selection, as well as device selection, is based on the outcome desired. Side effects are uncommon and preventable.

Photoaging: Mechanisms and repair

Aging is a complex, multifactorial process resulting in several functional and esthetic changes in the skin. These changes result from intrinsic as well as extrinsic processes, such as ultraviolet radiation. Recent advances in skin biology have increased our understanding of skin homeostasis and the aging process, as well as the mechanisms by which ultraviolet radiation contributes to photoaging and cutaneous disease. These advances in skin biology have led to the development of a diversity of treatments aimed at preventing aging and rejuvenating the skin. The focus of this review is the mechanism of photoaging and the pathophysiology underlying the treatments specifically designed for its prevention and treatment.

LEARNING OBJECTIVES

At the conclusion of this learning activity, participants should be familiar with the mechanism of photoaging, the treatments for photoaging, and the data that supports the use of these treatments.

Nonablative Remodeling with a 1,540 nm Erbium:Glass Laser

BACKGROUND

Nonablative remodeling has recently been proposed as a new antiaging treatment with no downtime. This technique could greatly benefit the increasing numbers of patients who are looking for new and efficient techniques, with a minimum of discomfort.

MATERIALS

AND METHODS. The 1.54 microm wavelength has been proposed for this application because this wavelength is well absorbed by water yet virtually not at all by melanin, allowing deep penetration into the skin. To protect the epidermis during laser irradiation, a cooling system (+5 degrees C) uses a sapphire window (purified tetrafluoroethane circulates in a pipe around the sapphire) directly applied to the skin through which the laser pulse may be fired.

RESULTS

Several clinical trials have been published and have demonstrated that clinical improvement was correlated with data from ultrasound imaging, histology, and profilometry. A recent trial on the forehead and neck yielded additional data on elasticity measured by echorheometry.

CONCLUSIONS

The 1.54 microm laser is safe and effective for remodeling in all of these published studies. Remodeling requires months to achieve its goal, and the kind of improvement that can be expected should be explained to the patient. Long-term follow-up showed that the improvement increased after each treatment and lasted for months after the final session.

Dermal matrix remodeling after nonablative laser therapy

OBJECTIVE

Nonablative laser therapy is widely practiced for cutaneous rejuvenation. We sought to quantify dermal molecular changes after exposure of photodamaged skin to nonablative laser energy.

METHODS

Nonablative laser therapy of forearm skin using either a 585-nm wavelength pulsed dye laser or a 1320-nm wavelength neodymium:yttrium-aluminum-garnet laser was performed. Serial biopsy specimens were obtained at baseline and various times after treatment.

RESULTS

Statistically significant increases in type I procollagen messenger RNA expression occurred after exposure of photodamaged skin to each laser. Induction was 47% (P < .05) and 84% (P < .05) above baseline levels 1 week after laser therapy among those treated with the pulsed dye and neodymium:yttrium-aluminum-garnet lasers, respectively. Substantial induction of type III procollagen, various matrix metalloproteinases, and primary cytokines was also demonstrated. Responses with respect to all molecules studied were highly variable.

LIMITATIONS

This study addresses molecular changes after a single laser exposure whereas clinically, serial treatments are often provided.

CONCLUSIONS

Nonablative laser therapy may result in quantifiable alterations in molecules associated with remodeling of the dermal matrix, although responses vary greatly among patients.

Periorbital Ablative and Nonablative Resurfacing

Ablative resurfacing using laser systems for facial rejuvenation, especially in the periorbital areas, has effectively replaced chemical peels. Refined methods yield outstanding efficacy with significantly fewer side effects as compared with the prototypical lasers of decades past. Despite these technologic refinements, the trend toward minimally invasive rejuvenation techniques has placed a substantial emphasis on the many nonablative modalities available to the practitioner. Although the clinical efficacy to date has been less with the nonablative devices, the lack of substantial morbidity has made the devices marketable to a large population of patients despite their modest results at best and highly unpredictable results at worst. Numerous options, ablative and nonablative, are now available for the patient desiring improvement in periorbital rhytids.

Using light in dermatology: an update on lasers, ultraviolet phototherapy, and photodynamic therapy

Indications for light-based treatments, such as lasers, UV phototherapy, and photodynamic therapy, are rapidly increasing within the arena of skin disorders. Physicians can remain current in their understanding of these modalities if they understand a few basic principles outlined in this article. Once these concepts are understood, all the rapid advances can be kept in perspective and physicians can apply the most appropriate technology to the care of their patients while informing them about the limitations of overmarketed but poorly proved strategies.

Nonablative laser and light therapies for skin rejuvenation

BACKGROUND

Multiple modalities have been described for skin rejuvenation, including ablative and nonablative therapies. Because of the prolonged recovery period associated with ablative procedures that injure the epidermis, nonablative skin treatments have grown increasingly popular. Various laser- and light-based systems have been designed or applied for promoting skin remodeling without damage to the epidermis.

METHODS

Studies investigating the use of nonablative procedures for facial rhytids or acne scarring with clinical, histological, and objective quantitative measurements are systematically reviewed.

RESULTS

Nonablative treatments are associated with clinical and objective improvements for the treatment of facial rhytids and acne scarring. Dermal remodeling seems to occur as a result of thermal injury, leading to dermal fibrosis without epidermal disruption.

CONCLUSIONS

Although results are not as impressive as those of ablative treatments, nonablative procedures are effective in the treatment of photoaging and acne scarring. As technology in nonablative therapies continues to evolve, future laser and light sources may yield even more favorable results.

Results of nonablative wrinkle reduction with a 1,450-nm diode laser: Difficulties in the assessment of “subtle changes”

BACKGROUND AND OBJECTIVE

Nonablative resurfacing has proven its efficacy in vascular and pigmented lesions, while its capacity of substantial wrinkle reduction is still discussed controversially. We present the treatment results of a 1,450 nm diode laser for facial rhytides.

METHODS

Thirty facial regions were treated with a 1,450 nm diode laser. Pre- and post treatment pictures were compared by the treating physician and two blinded observers.

RESULTS

Even if mild improvement was rated in up to 35% of the post treatment pictures, a discrepancy shows up in the assessments of the three observers, presenting almost no congruency in the rating of improvement.

CONCLUSIONS

Our study failed to provide convincing data on the efficacy of nonablative treatment of rhytides with the 1,450 nm diode laser. In this respect, we challenge objective judgment in the assessment of subtle changes in nonablative wrinkle reduction.