Wrinkle Reduction with Nonablative Lasers

Published on 26/02/2015 by admin

Filed under Dermatology

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 2354 times

28 Wrinkle Reduction with Nonablative Lasers

Rebecca Small, MD

Nonablative laser treatments for wrinkle reduction (where the term lasers* refers to both lasers and intense pulsed light devices) are aimed at heating the dermis to cause mild injury, while leaving the epidermis intact. A reparative healing process ensues after treatment with collagen shrinkage and synthesis of new collagen and extracellular matrix, referred to as dermal collagen remodeling.1,2 Dermal thickness is increased and the skin is smoothed, resulting in clinical reduction of wrinkles. In addition to wrinkle reduction, collagen remodeling effects with nonablative lasers can also result in reduction of depression scars, pore size, and rough skin texture.

Nonablative lasers are most appropriate for treatment of mild to moderate wrinkles (also called rhytids). Relative to ablative technologies, wrinkle reduction effects are slower and more subtle with nonablative technologies. However, these treatments have the advantage of requiring little to no recovery time, they have lower risks of complications, and are easily incorporated into patients’ daily lives. Common terms used for nonablative wrinkle reduction include nonablative skin rejuvenation, noninvasive resurfacing, and skin toning.

Certain nonablative laser technologies primarily target skin laxity and skin folds. Reduction of skin laxity and folds is commonly known as skin tightening; however, the term used by the Food and Drug Administration (FDA) is soft tissue coagulation, which essentially means thermal injury to the skin. Providers may want to consider using terms such as reduction of skin laxity or crepiness (defined as a crepey or crinkly appearance to the skin) rather than skin tightening, because for some patients, skin tightening may imply surgical-like results with dramatic tissue lifting.

Rejuvenation of photoaged skin typically requires reduction of wrinkles and rough texture in combination with treatment of dyschromia (such as solar lentigines and mottled hyperpigmentation) and vascular ectasias (such as telangiectasias and facial erythema). Nonablative wrinkle reduction with lasers is an important component of aesthetic care and can be readily combined with other minimally invasive aesthetic procedures into office practice to achieve global skin rejuvenation.

Laser Principles and Devices Currently Available

The mechanism by which most nonablative lasers effect collagen remodeling and wrinkle reduction is through focal thermal injury to the dermis while avoiding epidermal injury. Thermal injury can be induced through energy absorption in the skin by melanin, oxyhemoglobin, and/or water chromophores utilizing the principle of selective photothermolysis (see Chapter 19, Aesthetic Principles and Consultation).3 Other methods of inducing thermal injury include using radio-frequency energy, where tissue resistance to applied current heats the dermis. Some technologies utilize fractional methods of delivery that enhance the depth of laser penetration into the skin. Nonablative wrinkle reduction technologies can be broadly classified according to their clinical effects of wrinkle reduction or improvement in skin laxity, and this may be further refined based on the mechanism of action of the technology (see Table 28-1).

TABLE 28-1 Classification of Nonablative Lasers and Light Devices for Wrinkle Reduction

image

Wrinkle Reduction

Many of the lasers used for nonablative wrinkle reduction target the water chromophore in tissue, including infrared (IR) wavelengths of 1320, 1440, 1450, 1540, and 1550 nm (1064 nm is also an IR wavelength but has less affinity for water). Figure 28-1 shows these wavelengths superimposed on the water absorption curve. By heating water, thermal energy is conducted to the dermal tissue, which stimulates the collagen remodeling process. All of these wavelengths have demonstrated clinical improvements in wrinkles.4–7

image

FIGURE 28-1 Water absorption spectrum and common nonablative wrinkle reduction lasers.

Some of the infrared lasers employ a fractional method of delivery (see Table 28-1), of which 1550 nm has the most data.8 Fractional lasers treat a portion or “fraction” of the skin by delivering laser energy in microscopic columns, called microthermal zones. Figure 19-10 in Chapter 19, Aesthetic Principles and Consultation, shows the pattern in the skin made by fractional laser devices. The untreated tissue between microthermal zones serves as a regenerative reservoir, which facilitates rapid wound healing.9 This type of treatment is termed nonablative fractional resurfacing. In addition to the collagen remodeling effects of wrinkle and scar reduction, fractional resurfacing with 1550 nm has also shown promise with reduction of dyschromic conditions such as melasma and poikiloderma of Civatte.10–12

Lasers that target oxyhemoglobin, melanin, and to a lesser degree water, such as 532 nm pulsed dye lasers (585 and 595 nm), and intense pulsed light devices (IPLs) have also been found to effect collagen remodeling and wrinkle reduction.13–15 However, the primary indication for these chromophore dependent lasers is reduction of vascular ectasias and/or pigmented lesions.

The Q-switched 1064 nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser was one of the first lasers to demonstrate nonablative reduction of wrinkles. Long-pulse 1064 nm Nd:YAG lasers are also used for reduction of wrinkles and results may be enhanced when combined with 532 nm.16–18 The long 1064 nm wavelength, as with other infrared lasers, allows for deep penetration to the dermis, which is desirable for collagen remodeling and, because it has little absorption by epidermal pigment, this wavelength is safe for all skin types. Studies with Q-switched 1064 nm lasers demonstrate histologic19,20 and clinical reduction of wrinkles, as well as other collagen remodeling effects, such as reduction of pore size, rough skin texture,21 and superficial acne scarring.22–24 Dermal collagen remodeling effects are due to both photothermal and photoacoustic vibration, which results from the inherent rapid, short (nanoseconds) pulses of Q-switched lasers.25 In addition to dermal remodeling, Q-switched 1064 nm lasers are also commonly used for tattoo removal,26 reduction of dermal pigmentation such as melasma,27–29 and reduction of fine dark hair.30 The diverse applications of Q-switched 1064 nm and other chromophore-dependent lasers offer a means to address many aesthetic skin complaints simultaneously.

Light-emitting diodes (LEDs) are a newer type of light-based device that emit a narrow range, or band, of wavelengths. They do not operate based on the theory of selective photothermolysis, but are instead based on the principle of photomodulation, whereby cellular activity is modulated through illumination with particular wavelengths of light.31 These devices have been used for mild wrinkle reduction32 and treatment of acne. Several LEDs are available that vary in wavelength and pulsing modes such as blue light devices (400 to 500 nm) which have superficial penetration, and red light devices (570 to 670 nm) which have deeper penetration. The main advantage of LEDs is their ease of use.

LEDs have also been used for skin rejuvenation as part of photodynamic therapy (PDT). PDT refers to selective tissue destruction through the use of a photosensitizing medication that is activated by a laser or light-based device (such as an LED or IPL).33 A topical photosensitizing medication such as aminolevulinic acid (Levulan®) is concentrated in particular tissues, such as sebaceous glands and actinically damaged cells. The photosensitizer is activated by a light source resulting in a cytotoxic reaction and destruction of the targeted areas.34 PDT is currently FDA approved for treatment of nonhyperkeratotic actinic keratoses, but is used off label to enhance the results with nonablative lasers for photorejuvenation and wrinkle reduction.35–37

Reduction of Skin Laxity

Skin laxity is treated with two main types of technologies: broadband infrared and radio-frequency (RF) devices.38 The improvements in laxity are believed to be due to collagen contraction initially, and later to collagen synthesis.39 Broadband infrared devices (such as the Cutera Titan™) emit wavelengths ranging from 1100 to 1800 nm with long pulse widths (of several seconds). Radio-frequency devices (such as Solta Thermage™) employ rapidly alternating current that creates heat when applied to the skin because of the skin’s resistance to the flow of current. Tissue heating with RF devices is controlled by several factors, including the type of electrodes used (e.g., monopolar or bipolar), fluence, and cooling times. These technologies have been shown to improve laxity in many areas of the body including the periocular region, nasolabial folds, jowls, neck, and abdomen.40–45 In addition to treatment of wrinkles and skin laxity, RF devices are also used for cellulite reduction.46 RF treatments have traditionally been associated with more discomfort than IR treatments, however, new techniques utilizing multiple passes with lower fluences have improved tolerability.47

Epidermal Cooling

Cooling of the skin is an important consideration with nonablative wrinkle reduction treatments. Adequate cooling is required to protect the epidermis, but overcooling can reduce clinical effects. In addition, overcooling can induce epidermal injury, particularly in darker Fitzpatrick skin types, resulting in postinflammatory hyperpigmentation. Some nonablative lasers utilize cryogen spray coolants (e.g., 1320 nm) or contact cooling through the tip of the device (e.g., broadband IR). The shorter wavelength devices (e.g., 532 nm and pulsed dye lasers) also employ larger spot sizes with lower fluences to further reduce the risk of epidermal injury. IPL devices have large spot sizes and typically use contact cooling. Due to minimal epidermal energy absorption by 1064 nm and the relatively lower fluences used for wrinkle reduction treatments (compared to leg veins, for example), these devices do not typically utilize cooling.

Patient Selection

Patient selection for wrinkle reduction treatments with nonablative lasers is based on the degree of wrinkling present and patient expectations. Patients with mild to moderate static wrinkles and laxity (Glogau types I through III) are appropriate candidates (see Chapter 19, Aesthetic Principles and Consultation, for a description of Glogau types). Patients with deep static wrinkles and/or severe laxity (Glogau type IV) and those who desire more rapid and dramatic results may be better candidates for more aggressive procedures such as ablative laser resurfacing or surgery.

In patients presenting with wrinkling as well as significant dyschromia and vascular ectasias, the dyschromia and vascularities are typically treated first, using technologies/therapies most appropriate for the predominant presenting issue. Improvements in texture and wrinkles will be more apparent after these other issues have been addressed.

Results with nonablative wrinkle reduction treatments occur slowly, usually 2 to 3 months after the initial laser treatment, and improvements may continue to be seen 6 months post-treatment. A series of five to six treatments is usually required at monthly intervals. Some improvements may be seen immediately post-treatment; however, this is likely due to transient tissue edema. Assessment of patients’ expectations at the time of consultation and commitment to a series of treatments is essential to ensure success with these treatments.

Patients with darker skin Fitzpatrick skin types (IV through VI) have increased risks of complications, such as hyperpigmentation and hypopigmentation, and are best suited to treatment with nonablative lasers that target water (e.g., 1320 nm) and those with longer wavelengths (e.g., 1064 nm). Lighter Fitzpatrick skin types (I through III) may be treated with any of the nonablative laser technologies including those with shorter wavelengths (e.g., 532 nm and pulsed dye lasers).

Indications

• Mild to moderate rhytids
• Mild to moderate skin laxity and crepiness (with RF and broadband IR devices).

Alternative Therapies

Ablative skin resurfacing, with carbon dioxide and erbium lasers, is the gold standard for reduction of wrinkles. Although the fractional method of delivery has reduced the associated recovery time and risk of complications, ablative laser treatments create an open wound and are considered aggressive treatments. Although more aggressive procedures offer greater potential for wrinkle reduction, they require longer recovery times and have greater risks of complications.

Nonlaser treatment options for wrinkle reduction include superficial skin resurfacing with light chemical peels or microdermabrasion, and topical skin care products such as retinoids and exfoliants. More aggressive resurfacing can be performed with deeper chemical peels and operative procedures such as dermabrasion, which utilizes a motorized rotating wire-bristle brush to abrade the skin.

Products Currently Available

See the Resources section at the end of the chapter for a list of laser manufacturers.

Contraindications

See General Laser Contraindications in Chapter 26, Hair Reduction with Lasers.

Advantages of Nonablative Lasers for Wrinkles

• Relative to more aggressive resurfacing procedures, such as ablative treatments with carbon dioxide and erbium lasers, there is minimal recovery time and minimal risk of complications.
• Treatments are readily incorporated into patients’ daily lives and easily combined with other minimally invasive aesthetic procedures.
• Many technologies used for nonablative wrinkle reduction are appropriate for darker skin types (IV and V) and some are even safe with Fitzpatrick skin type VI. More aggressive resurfacing procedures (e.g., ablative laser resurfacing and medium-depth chemical peels) are typically restricted to Fitzpatrick skin types I through III.

Disadvantages of Nonablative Lasers for Wrinkles

• Clinical results are variable and not all patients will show demonstrable improvements.
• Wrinkle reduction is slow and may require months before becoming clinically evident.
• Subtle results may not be captured photographically.

Anatomy

Wrinkles result from many factors including skin changes with epidermal hypocellularity, loss of dermal matrix components including collagen, glycosaminoglycans, elastin, and atrophy of subcutaneous adipose tissue. Thinning of the skin combined with repetitive contraction of underlying musculature can etch wrinkles into the skin to form static lines.48

Nonablative laser treatments are aimed at reducing mild to moderate static wrinkles. Most of these technologies do so by producing papillary dermal injury, at an approximately 100 to 200 µm (0.1 to 0.2 mm) depth in the skin.49,50 Fractional nonablative laser treatments for wrinkles (e.g., fractional 1550 nm) penetrate up to 300 to 400 µm (0.3 to 0.4 mm).9 Nonablative lasers for laxity (e.g., RF lasers) penetrate to the reticular dermis, up to 1 to 3 mm.51

Equipment

• Laser or IPL device appropriate for wrinkle reduction treatments
• Eyewear for the patient and provider specific to the device being used
• Nonalcohol cleansing facial wipes
• Clear colorless gel for treatments if necessary per the manufacturer
• 4 × 4 inch gauze
• Ice packs
• Soothing nonocclusive topical product (e.g., SkinCeuticals Epidermal Repair™)
• Broad-spectrum sunscreen (SPF 30 with zinc or titanium)
• Hydrocortisone cream 1% and 2.5%
• Alcohol wipes for cleaning laser tip
• Germicidal disposable wipes for sanitizing the laser.

Procedure Preparation

1. Perform an aesthetic consultation and review the patient’s medical history (see Chapter 19, Aesthetics Principles and Consultation) including history of postinflammatory hyperpigmentation, abnormal scarring, photosensitizing medications or isotretinoin, and previous dermal fillers in the treatment area.
2. Examine the treatment area including assessment of the degree of wrinkling (see Chapter 19 for a discussion of Glogau types). Consider referral for ablative skin resurfacing or surgical intervention in patients with excessive laxity and severe wrinkling (e.g., Glogau type IV).
3. Obtain informed consent (see Chapter 19; also see Appendix A for an informed consent form and patient information handout titled Nonablative Laser Treatments for Wrinkle Reduction).
4. Take pretreatment photographs (see Chapter 19).
5. Determine the Fitzpatrick skin type (see Chapter 19).
6. If the patient has a prior history of herpes simplex or varicella in or near the treatment area, provide prophylactic antiviral medication (e.g., valacyclovir, 500 mg, 1 tablet twice daily) for 2 days prior to the procedure, and continue for 3 days postprocedure.
7. Consider performing test spots prior to the initial treatment for patients with darker Fitzpatrick skin types (types IV through VI). Laser manufacturer’s guidelines for spot size, fluence, and pulse width should be followed. Test spots are placed discretely (under the chin, behind or inferior to the ear) near the desired treatment area and viewed 3 to 5 days after placement for evidence of erythema, burn, or other adverse effect. Inform patients that lack of an adverse reaction with test spots does not ensure that a side effect or complication will not occur with any treatment.
8. Pretreatment skin care products, other than a daily sunscreen, are not required; however, patients will derive added benefit from using rejuvenation skin care products (see Chapter 24, Skin Care Products).

Nonablative Lasers for Wrinkles: Steps and Principles

The following guidelines are based on treatment of mild to moderate facial wrinkling using a Q-switched 1064 nm laser (Hoya ConBio RevLite™), which is indicated for all Fitzpatrick skin types. Manufacturer’s guidelines for the specific device used should be followed at the time of treatment.

General Treatment Technique

1. Treatment is performed on the full face within the safety zone (see below for safety zone region).
2. Laser treatment parameters are based on the patient’s Fitzpatrick skin type. Darker skin types require more conservative settings with the Q-switched 1064 nm laser of larger spot sizes and lower fluences:

• Fitzpatrick skin type VI: 8 mm spot size, 1.4 to 2.0 J/cm2
• Fitzpatrick skin types IV–V: 8 mm spot size, 2.0 to 3.0 J/cm2 (PTP mode 3.5 J/cm2; see Tip below for PTP mode description)
• Fitzpatrick skin types I–III: 6 mm spot size, 2.5 to 3.5 J/cm2 (PTP mode 6.9 J/cm2).

TIP: Certain Q-switched devices have stacked-pulse modes that allow for higher fluencies (e.g., photoacoustic technology pulse (PTP) mode with the Q-switched RevLite). Once fluences are maximized in the non-PTP mode, the PTP mode may be used. Due to the method of delivery, high fluences used in the PTP mode typically do not cause additional patient discomfort. For example, a 6-mm spot size with 3.5 J/cm2 in non-PTP mode results in the same patient discomfort as a 6-mm spot with 6.9 J/cm2 in the PTP mode.
3. It is advisable to start at the periphery of the face and progress medially, because the central face is more sensitive. Figure 28-2 shows a recommended sequence for treating the face in regions, starting with area 1 and progressing to area 6.
TIP: The most sensitive facial areas are the upper lip (philtrum) and lateral to the nose.
4. The handpiece for Q-switched 1064 nm lasers is held approximately 1 inch above the skin, which is determined by the handpiece depth guide (Figure 28-3). It is moved in a painting motion across the face using long switchback strokes (Figure 28-4). The direction of the laser handpiece is toward the provider, with approximately 20% overlap of each pulse. The laser tip should always be angled away from the eyes during treatment.
image

FIGURE 28-2 Nonablative Laser Safety Zone and sequence for wrinkle reduction treatments on the face.

(Copyright Rebecca Small, MD.)

image

FIGURE 28-3 Technique for nonablative wrinkle reduction treatments using a Q-switched 1064 nm laser.

(Copyright Rebecca Small, MD.)

image

FIGURE 28-4 Handpiece direction for nonablative wrinkle reduction treatments using a Q-switched 1064 nm laser.

(Copyright Rebecca Small, MD.)

Planning and Designing

• Q-switched 1064 nm lasers are chromophore dependent and this wavelength is selectively absorbed by melanin. In addition to collagen remodeling effects which include reduction of wrinkles, acne scars, rough texture, and coarse pores, they are also used for:

• Dermal hyperpigmentation (such as melasma)
• Temporary reduction of fine dark hair.

• If these lesions are present in the area for wrinkle reduction, fluences at the lower recommended range (see above) should be used due to the greater amount of target in the skin.
• A 1064 nm wavelength can also reduce fine darkly pigmented hairs. This is an advantage for women with facial hair. However, facial hair reduction may not be desirable in men and this should be discussed prior to treatment.

Anesthesia

Anesthesia is not required for nonablative wrinkle reduction treatments.

Safety Zone

The area within which lasers may be used for wrinkle reduction treatments on the face is called the Nonablative Laser Safety Zone (Figure 28-2). Laser treatments are performed outside of the orbit: above the supraorbital ridge (above the eyebrows) and below the inferior orbital rim, to reduce the risk of ocular injury.

Performing the Procedure

1. Inquire about sun exposure and sunscreen use at every visit. If the patient is recently sun exposed or tan, wait 1 month before treating to reduce the risk of complications.
2. Position the patient supine on a flat treatment table.
3. Cleanse the skin with a nonalcohol wipe.
4. Provide appropriate laser-safe eye protection for the patient and all personnel in the treatment room prior to beginning treatment.
5. Always operate the laser in accordance with your office’s laser safety policies and the manufacturer’s guidelines.
6. Tattoos and permanent makeup should be covered with wet gauze and the laser tip kept at least 1 inch away from them during treatment.
7. Perform a single pulse at the lateral margin of treatment area 1 and assess for patient tolerance and clinical endpoints (see below). In general, there are subtle endpoints with initial treatments, and pain should be less than or equal to 5 on a scale of 1 to 10.
8. Desirable clinical endpoints include:

• Fitzpatrick skin types I–III: mild to moderate erythema (Figure 28-5)
• Fitzpatrick skin types IV–VI: mild or no erythema
• Pigmented lesion darkening (especially dermal lesions, such as melasma) with enhanced demarcation against the background skin (Figure 28-6)
• Papular acne lesions: mild to moderate erythema
• Vaporization of sebum in sebaceous facial areas such as the nose and chin, and areas with coarse pores and comedonal acne (Figure 28-7)
• Audible snapping sound with laser pulses, loudest over sebaceous areas.

9. Petechiae (see Figure 28-15 later in this chapter) may be seen with aggressive treatment parameters. If these occur during treatment, the fluence should be reduced or the spot size increased to reduce treatment intensity. The treatment may be continued but the petechial area should not receive additional passes.
10. Perform one pass (where a pass is full coverage of the treatment area) to the entire face. If there is mild to no erythema, perform a second pass to the treatment area. In areas with wrinkles, hyperpigmentation, papular acne, or coarse pores, perform up to three to four additional passes, or until the desired endpoints have been reached.
11. Adjust laser settings based on observations of laser/tissue interaction, clinical endpoints, and patient discomfort throughout treatment.
12. At subsequent visits, the intensity of treatments may be increased by either:

• Increasing the fluence
• Decreasing the spot size
• Increasing the number of passes.

In general, only one parameter is changed to intensify treatments in any given visit. Typically, the fluence or number of passes is increased initially for a few treatments to achieve desired clinical endpoints, and spot size is decreased in later treatments.
13. After treatment, apply a soothing topical nonocclusive product (e.g., SkinCeuticals Epidermal Repair) and broad-spectrum sunscreen (SPF 30 with zinc or titanium). If the treatment area is significantly erythematous, hydrocortisone cream 1% to 2.5% may also be applied. Ice is generally not necessary unless there is a reported area of discomfort and should not be used unless needed, because the desired thermal reaction in the skin continues for a short while after treatment and it is terminated upon application of ice.
image

FIGURE 28-5 Clinical endpoint of mild erythema (A) before and (B) immediately after a nonablative wrinkle reduction treatment using a Q-switched 1064 nm laser.

(Copyright Rebecca Small, MD.)

image

FIGURE 28-6 Clinical endpoint of hyperpigmentation darkening (A) before and (B) immediately after a nonablative wrinkle reduction treatment using a Q-switched 1064 nm laser.

(Copyright Rebecca Small, MD.)

image

FIGURE 28-7 Clinical endpoint of sebum vaporization on the chin during a nonablative wrinkle reduction treatment using a Q-switched 1064 nm laser.

(Copyright Rebecca Small, MD.)

Results

Treatments are performed in a series, and most nonablative wrinkle reduction lasers show improvements approximately 3 months after the initial treatment, with continued improvements up to 6 months following the last treatment. It is extremely important to inform patients that reduction of mild to moderate wrinkles with nonablative lasers is slow and results vary based on the technology used and with individual patients. Studies of nonablative lasers consistently show histologic improvements with increased numbers of fibroblasts and collagen deposition.23,52 However, clinical improvements are less predictable and do not always correlate with histologic changes. Figures 28-8 through 28-14 show before and after photos for some of the nonablative wrinkle reduction technologies discussed in the chapter.

image

FIGURE 28-8 Facial wrinkles (A) before and (B) after a series of six treatments with a long-pulse 1064 nm Nd:YAG laser.

(Courtesy of Cutera, Brisbane, CA; laser genesis; photograph by K. Smith.)

image

FIGURE 28-9 Infraocular wrinkles (A) before and (B) after a series of treatments with a Q-switched 1064 nm Nd:YAG laser.

(Courtesy of HOYA ConBio, Fremont, CA; laser toning by D. Goldberg, MD, using RevLite.)

image

FIGURE 28-10 Cheek wrinkles, crow’s feet, and hyperpigmentation (A) before and (B) after nonablative fractional resurfacing treatments using a 1550 nm laser.

(Courtesy of Solta, Hayward, CA; Z. Rahman, MD, using Fraxel Re:store™.)

image

FIGURE 28-11 Acne scars (A) before and (B) after nonablative fractional resurfacing treatments using a 1550 nm laser.

(Courtesy of Solta, Hayward, CA; Z. Rahman, MD, using Fraxel Re:store™.)

image

FIGURE 28-12 Skin laxity of the lower face (A) before, (B) 6 months after, and (C) 3 years after a series of RF laser treatments.

(Courtesy of Solta, Hayward, CA; F. Mayoral, MD, using Thermage™.)

image

FIGURE 28-13 Skin laxity of the neck (A) before and (B) after a series of RF laser treatments.

(Courtesy of Solta, Hayward, CA; R. Euwer, MD, using Thermage™.)

image

FIGURE 28-14 Skin laxity of the abdomen (A) before and (B) after a series of broadband IR laser treatments.

(Courtesy of Cutera, Brisbane, CA; J. Calkin, MD, using Titan™.)

Figure 28-8 shows results of nonablative wrinkle reduction treatments for facial rhytids (A) before and (B) after a series of six treatments with a long-pulse 1064 nm Nd:YAG laser (Cutera Laser Genesis™).

Figure 28-9 shows results of nonablative wrinkle reduction treatments for infraocular rhytids (A) before and (B) after a series of treatments with a Q-switched 1064 nm Nd:YAG laser (HOYA ConBio RevLite™).

Figure 28-10 shows wrinkle reduction treatments for cheek rhytids and crow’s feet, as well as hyperpigmentation reduction (A) before and (B) after fractional resurfacing treatments using a 1550 nm laser (Solta Fraxel Re:store™).

Figure 28-11 shows results of nonablative collagen remodeling treatments for acne scars (A) before and (B) after fractional resurfacing treatments using a 1550 nm laser (Solta Fraxel Re:store™).

Figure 28-12 shows results of nonablative skin laxity reduction treatments of the lower face (A) before, (B) after 6 months, and (C) after 3 years following a series of RF treatments (Solta Thermage™).

Figure 28-13 shows results of nonablative skin laxity reduction treatments of the neck (A) before and (B) after a series of RF laser treatments (Solta Thermage™).

Figure 28-14 shows results of nonablative skin laxity reduction treatments of the abdomen (A) before and (B) after a series of broadband infrared treatments (Cutera Titan™).

Aftercare

Mild swelling and mild erythema are expected and usually resolve within 15 minutes to 1 hour after treatment. If patients report areas that feel hot, or have more significant erythema, a wrapped ice pack may be applied for 15 minutes every 1 to 2 hours and hydrocortisone cream 1 to image% two times per day for 3 to 4 days or until redness resolves. Patients are instructed to contact their provider if erythema persists for more than 5 days because postinflammatory hyperpigmentation (PIH) can occur with prolonged erythema (see complications below). Patients should avoid direct sun exposure for 1 to 2 days after treatment to help minimize the risk of pigmentary changes and use a broad-spectrum sunscreen (SPF 30 with zinc or titanium) daily.

Follow-Up

Nonablative laser treatments for wrinkle reduction typically require a series of six treatments at monthly intervals for demonstrable improvements, although fewer treatments may be required for fractional lasers. It is generally accepted that results persist for 1 to 2 years. Figure 28-12 shows recurrence of lower face laxity 3 years after RF treatment. Patients may, therefore, want to consider repeating a treatment series every 2 years. Alternatively, because these treatments are so well tolerated and results are cumulative, some providers recommend performing nonablative laser treatments as part of regular skin maintenance at monthly to quarterly intervals.

Complications

• Erythema
• Swelling
• Pain
• Petechiae/purpura (Figure 28-15)
• Urticaria (Figure 28-16)
• Hyperpigmentation
• Hypopigmentation
• Burn with blistering and scabbing
• Scarring (extremely rare)
• Inadequate collagen remodeling effects including lack of reduction of: wrinkles, folds, skin crepiness, laxity, scars, or recurrence after completion of treatments
• Damage or alteration to tattoos and permanent makeup
• Infection (e.g., herpes simplex)
• Hair reduction in or adjacent to the treatment area
• Alteration to dermal filler
• Ocular injury.
image

FIGURE 28-15 Petechiae of the neck with a nonablative laser wrinkle reduction treatment.

(Copyright Rebecca Small, MD.)

image

FIGURE 28-16 Preauricular urticaria with a nonablative laser wrinkle reduction treatment.

(Copyright Rebecca Small, MD.)

Nonablative laser treatments for wrinkle reduction and skin crepiness have minimal risks of side effects and complications. However, complications are possible with any laser procedure, and knowledge of these is important to help ensure the best possible outcomes.

Mild erythema and swelling are to be expected, as mentioned earlier. Prolonged erythema for 5 days or more may result from contact dermatitis, which can occur in response to topical products, and can be managed with a topical steroid such as triamcinolone cream 0.025% two times per day for 1 week and discontinuation of the offending product. Swelling may occur, particularly with aggressive treatment of the cheeks. Cold compresses are recommended as described above and a daily oral antihistamine (e.g., cetirizine 10 mg) until resolved.

Pain is mild and rarely reported to be greater than 4 or 5 (on a standard pain scale of 1 to 10) during treatment; however, RF treatments tend to be uncomfortable and may require premedication with an analgesic such as hydrocodone (Vicodin).

Petechiae may be seen with high fluences particularly in thin-skinned areas such as the neck (Figure 28-15). Purpura may occur with shorter wavelength lasers, particularly pulsed dye lasers, and when short pulse widths and/or high fluences are utilized during treatment.53 Petechiae typically take 3 to 5 days to resolve and purpura can take up to 2 weeks. Utilizing larger spot sizes, lower fluences, and skin compression can reduce the incidence of purpura with devices that are prone to purpura formation.54

Rarely, urticaria may be seen with lasers (Figure 28-16).55 This may be treated with cold compresses and an oral antihistamine (e.g., cetirizine 10 mg), which may be continued daily until resolved. Once identified, these patients may be pretreated for subsequent treatments with an antihistamine 1 hour prior to procedure.

Pigmentary complications of hyperpigmentation and hypopigmentation are rare, but may be seen in darker Fitzpatrick skin types (IV through VI) and patients with a recent tan. These complications are more common with devices that utilize short wavelengths (e.g., 532 nm and pulsed dye lasers) and with laser parameters of short pulse widths and/or high fluences. Inadequate epidermal cooling as well as overly aggressive cooling can also result in pigmentary changes. Hyperpigmentation is usually transient (and rarely may be permanent), lasting on the order of months. Postinflammatory hyperpigmentation has been reported with nonablative fractional devices56,57 and has been observed as a result of epidermal injury due to overcooling by the cryogen sprays used with some infrared devices.58 If PIH occurs, patients may use a topical lightening agent such as hydroquinone (4 to 8%) twice daily along with an exfoliating product (such as lactic or glycolic acid) and/or a retinoid. (See Chapter 24, Skin Care Products, for more about treatment of PIH.) The use of a lightening agent for 1 month prior to treatment may reduce the risk of PIH, particularly in darker Fitzpatrick skin types. Hypopigmentation is a more significant complication and, although often temporary, may be permanent.

A burn and/or scar may also occur, particularly with devices that utilize short wavelengths (e.g., 532 nm and pulsed dye lasers),59,60 aggressive treatment parameters of short pulse widths, and high fluences or inadequate epidermal cooling. In addition, overtreatment can occur when treating above bony prominences because these areas are more prone to the buildup of heat, particularly with the lasers for skin laxity. Routine moist wound care should be used for these complications with application of an antibiotic ointment and bandage until healed. Tattoos and permanent make-up have concentrated ink pigments and treatment over these may result in a full-thickness skin burn.

Herpes simplex and varicella zoster may be reactivated in the treatment area. Pretreatment prophylaxis with an oral antiviral medication can reduce this risk (see the Procedure Preparation section earlier in this chapter).

Reduced hair growth in or adjacent to the treatment area may occur. This risk should be fully discussed if treating over men’s facial hair.

Alteration to dermal filler is controversial. Although some evidence suggests that lasers do not affect dermal fillers in tissue,61 other studies recommend using lasers as a treatment for undesired collections of dermal fillers to render them more moldable and reduce their appearance in the skin.62,63 The author does treat over facial areas with fillers using nonablative lasers but not with ablative lasers.

Ocular injury can be avoided by wearing appropriate laser-safe eyewear at all times during treatment, directing the laser tip away from the eye, and treating outside of the eye orbit.

Treating Specific Lesions/Areas

Melasma

Laser treatments of melasma may have variable results and in some cases, hyperpigmentation may become worse.

Nonfacial Areas

Nonfacial areas, such as the neck and chest, have fewer pilosebaceous units have delayed healing relative to the face. They have a greater risk of overtreatment and scarring, and it is advisable to treate conservatively in nonfacial areas.

Learning the Technique

Initial treatments may be performed on the face with one pass using conservative laser parameters of larger spot sizes and lower fluences in patients with light Fitzpatrick skin types (I through III).

Current Developments

Combination therapy utilizing nonablative lasers with other minimally invasive aesthetic procedures in the same visit is emerging as a new approach to skin rejuvenation64 (see Chapter 31, Combination Cosmetic Treatments). For example, the author combines a Q-switched 1064 nm nonablative laser treatment for dermal collagen remodeling, with superficial exfoliating procedures such as microdermabrasion and superficial chemical peels, on the same day to enhance wrinkle reduction results without increasing downtime or side effects.

Recent technological improvements in Q-switched devices, such as flat-topped beam profiles, have reduced tissue “hot spots” and the associated risk of petechiae. In addition, novel pulsing modes (e.g., photoacoustic technology pulse) have been developed that allow for greater peak power without additional patient discomfort.23

Fractional delivery of energy is a very promising new method of nonablative laser treatments. In addition to reduction of wrinkles and improvements in dyschromia, fractional 1550 nm skin resurfacing treatments have also demonstrated good success with scar reduction.12,65,66 Modifications to some of the newer 1550 nm fractional devices may reduce the incidence of postinflammatory hyperpigmentation.8

Newer approaches to reduction of skin laxity combine monopolar with bipolar radio-frequency, where the RF current travels more superficially in the skin.67 Some devices combine radio-frequency with light-based technologies for nonablative skin rejuvenation (termed ELOS™, electro-optical synergy).68

Photomodulation with LEDs is a relatively new, non–thermally mediated method of mild skin rejuvenation. Studies have yet to determine which pulsing modes are most efficacious and compare the different wavelengths. Combining LEDs, or other nonablative laser and light-based modalities, with photosensitizing medications for photodynamic therapy enhances rejuvenation results.36,69 Combination therapy with PDT and exfoliation treatments, such as microdermabrasion, to enhance penetration of photosensitizing medications may further improve results.70

Financial Considerations

Nonablative laser treatments for wrinkles are not reimbursable by insurance companies. The charges for treatments vary, and are largely determined by local prices. Individual treatment prices range from $200 to $500 for a single treatment to a large area such as the face, and $150 to $300 for a small area such as the neck. However, because wrinkle reduction treatments are most effective with a series of treatments, packages of treatments (usually six) may be offered so that patients achieve the best possible results. Box 28-1 lists the applicable ICD-9 codes.

Box 28-1 ICD-9 Codes

695.3 Rosacea
701.8 Wrinkling of skin
706.1 Acne, comedones
709.0 Dyschromia, unspecified
709.09 Melasma
709.2 Scarring

Conclusion

Nonablative wrinkle reduction laser technologies are a heterogeneous group, but are all similar in that they induce dermal collagen remodeling with collagen synthesis while maintaining an intact epidermis. They are gentle enough to be combined with other minimally invasive procedures and can be readily integrated into office-based aesthetic care. With advances in the methods of delivery and greater energies delivered to the skin, nonablative lasers continue to improve and expand their role in rejuvenation of photodamaged skin.

Resources

Aerolase
Phone: 877-379-2435
www.aerolase.com
Alma Lasers
866-414-ALMA
www.almalasers.com
Asclepion Laser Technologies
www.asclepion.com
CoolTouch
Phone: 877-858-COOL
www.cooltouch.com
Cutera
Phone: 888-4-CUTERA
www.cutera.com
Cynosure/Deka
Phone: 800-886-2966
www.cynosure.com
DermaMed USA
Phone: 888-789-6342
www.dermamedusa.com
Dinona
Phone: +82-2-578-0810
www.dinonainc.com
Energist
www.energist-international.com
Enlyten Medical Technologies
Phone: 877-365-9836
www.enlyten-mt.com
Focus Medical
Phone: 866-633-5273
www.focusmedical.com
HOYA ConBio
Phone: 800-532-1064
www.conbio.com
Iridex
Phone: 650-940-4700
www.iridex.com
Lasering
Phone: 866-471-0469
www.laseringusa.com
Light BioScience
Phone: 803-409-8025
www.gentlewaves.com
Lumenis
Phone: 408-764-3000
www.lumenis.com
Lutronic
Phone: 888-588-7644
www.lutronic.com
Med-Aesthetic Solutions
Phone: 760-942-8815
www.medaestheticsolutions.com
Novalis
Phone: 866-627-4475
www.novalismedical.com
Palomar
Phone: 800-725-6627
www.palomarmedical.com
Sciton
Phone: 888-646-6999
www.sciton.com
Solta Medical
Phone: 877-782-2286
www.solta.com
Syneron (formerly Candela)
Phone: 866-259-6661
www.syneron.com

References

1. Liu H, Dang Y, Wang Z, et al. Laser induced collagen remodeling: a comparative study in vivo on mouse model. Lasers Surg Med. 2008;40(1):13-19.

2. Goldberg DJ. Nonablative resurfacing. Clin Plast Surg. 2000;27(2):287-292. xi

3. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science. 1983;220(4596):524-527.

4. Lloyd JR. Effect of fluence on efficacy using the 1440 nm laser with CAP technology for the treatment of rhytids. Lasers Surg Med. 2008;40(6):387-389.

5. Goldberg DJ. Full-face nonablative dermal remodeling with a 1320 nm Nd:YAG laser. Dermatol Surg. 2000;26(10):915-918.

6. Fournier N, Dahan S, Barneon G, et al. Nonablative remodeling: a 14-month clinical ultrasound imaging and profilometric evaluation of a 1540 nm Er:glass laser. Dermatol Surg. 2002;28(10):926-931.

7. Paithankar DY, Clifford JM, Saleh BA, et al. Subsurface skin renewal by treatment with a 1450-nm laser in combination with dynamic cooling. J Biomed Opt. 2003;8(3):545-551.

8. Narurkar VA. Nonablative fractional resurfacing for total body rejuvenation. J Drugs Dermatol. 2008;7(4):352-355.

9. Manstein D, Herron GS, Sink RK. Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med. 2004;34:426-438.

10. Rahman Z, Alam M, Dover JS. Fractional laser treatment for pigmentation and texture improvement. Skin Therapy Lett. 2006;11(9):7-11.

11. Tannous Z. Fractional resurfacing. Clin Dermatol. 2007;25(5):480-486.

12. Tierney EP, Kouba DJ, Hanke CW. Review of fractional photothermolysis: treatment indications and efficacy. Dermatol Surg. 2009;35(10):1445-1461.

13. Zelickson BD, Kilmer SL, Bernstein E, et al. Pulsed dye laser therapy for sun damaged skin. Lasers Surg Med. 1999;25(3):229-236.

14. Goldberg DJ. New collagen formation after dermal remodeling with an intense pulsed light source. J Cutan Laser Ther. 2000;2(2):59-61.

15. Carniol PJ, Farley S, Friedman A. Long-pulse 532-nm diode laser for nonablative facial skin rejuvenation. Arch Facial Plast Surg. 2003;5(6):511-513.

16. Dayan SH, Vartanian AJ, Menaker G, et al. Nonablative laser resurfacing using the long-pulse (1064-nm) Nd:YAG laser. Arch Facial Plast Surg. 2003;5(4):310-315.

17. Dayan S, Damrose JF, Bhattacharyya TK, et al. Histological evaluations following 1,064-nm Nd:YAG laser resurfacing. Lasers Surg Med. 2003;33(2):126-131.

18. Lee MW. Combination visible and infrared lasers for skin rejuvenation. Semin Cutan Med Surg. 2002;21(4):288-300.

19. Goldberg DJ, Silapunt S. Histologic evaluation of a Q-switched Nd:YAG laser in the nonablative treatment of wrinkles. Dermatol Surg. 2001;27(8):744-746.

20. Cisneros JL, Rio R, Palou J. The Q-switched neodymium (Nd):YAG laser with quadruple frequency. Clinical histological evaluation of facial resurfacing using different wavelengths. Dermatol Surg. 1998;24(3):345-350.

21. Lee MC, Hu S, Chen MC, et al. Skin rejuvenation with 1,064-nm Q-switched Nd:YAG laser in Asian patients. Dermatol Surg. 2009;35(6):929-932.

22. Goldberg DJ, Silapunt S. Q-switched Nd:YAG laser: rhytid improvement by non-ablative dermal remodeling. J Cutan Laser Ther. 2000;2(3):157-160.

23. Berlin AL, Dudelzak J, Hussain M, et al. Evaluation of clinical, microscopic, and ultrastructural changes after treatment with a novel Q-switched Nd:YAG laser. J Cosmet Laser Ther. 2008;10(2):76-79.

24. Friedman PM, Jih MH, Skover GR, et al. Treatment of atrophic facial acne scars with the 1064-nm Q-switched Nd:YAG laser: six-month follow-up study. Arch Dermatol. 2004;140(11):1337-1341.

25. Yaghmai D, Garden JM, Bakus AD, et al. Photodamage therapy using an electro-optic Q-switched Nd:YAG laser. Lasers Surg Med. 2009;42(8):699-705.

26. Kilmer SL, Lee MS, Grevelink JM, et al. The Q-switched Nd:YAG laser effectively treats tattoos. A controlled, dose-response study. Arch Dermatol. 1993;129(8):971-978.

27. Cho SB, Kim JS, Kim MJ. Melasma treatment in Korean women using a 1064-nm Q-switched Nd:YAG laser with low pulse energy. Clin Exp Dermatol. 2009;34(8):e847-850.

28. Cho SB, Park SJ, Kim JS, et al. Treatment of post-inflammatory hyperpigmentation using 1064-nm Q-switched Nd:YAG laser with low fluence: report of three cases. J Eur Dermatol Venereol. 2009;23(10):1206-1207.

29. Anderson RR, Margolis RJ, Watenabe S, et al. Selective photothermolysis of cutaneous pigmentation by Q-switched Nd:YAG laser pulses at 1064, 532, and 355 nm. J Invest Dermatol. 1989;93(1):28-32.

30. Bakus AD, Garden JM, Yaghmai D, Massa MC. Long-term fine caliber hair removal with an electro-optic Q-switched Nd:YAG laser. Laser Surg Med. 2010;42(8):706-711.

31. Weiss RA, McDaniel DH, Geronemus RG, et al. Clinical experience with light-emitting diode (LED) photomodulation. Dermatol Surg. 2005;31(9 Pt 2):1199-1205.

32. Goldberg DJ, Amin S, Russell BA, et al. Combined 633-nm and 830-nm LED treatment of photoaging skin. J Drugs Dermatol. 2006;5(8):748-753.

33. Kennedy JC, Pottier RH, Pross DC. Photodynamic therapy with endogenous protoporphyrin IX: basic principles and present clinical experience. J Photochem Photobiol B. 1990;6(1–2):143-148.

34. Dover JS, Bhatia AC, Stewart B, et al. Topical 5-aminolevulinic acid combined with intense pulsed light in the treatment of photoaging. Arch Dermatol. 2005;141(10):1247-1252.

35. Uebelhoer NS, Dover JS. Photodynamic therapy for cosmetic applications. Dermatol Ther. 2005;18(3):242-252.

36. Alster TS, Tanzi EL, Welsh EC. Photorejuvenation of facial skin with topical 20% 5-aminolevulinic acid and intense pulsed light treatment: a split-face comparison study. J Drugs Dermatol. 2005;4(1):35-38.

37. Bjerring P, Christiansen K, Troilius A, et al. Skin fluorescence controlled photodynamic photorejuvenation (wrinkle reduction). Lasers Surg Med. 2009;41(5):327-336.

38. Kaufman J. Lasers and light devices. In: Baumann L, editor. Cosmetic Dermatology. New York: McGraw-Hill; 2009:212-220.

39. Dierickx CC. The role of deep heating for noninvasive skin rejuvenation. Lasers Surg Med. 2006;38(9):799-807.

40. Carniol PJ, Dzopa N, Fernandes N, et al. Facial skin tightening with an 1100–1800 nm infrared device. J Cosmet Laser Ther. 2008;10(2):67-71.

41. Goldberg DJ, Hussain M, Fazeli A, et al. Treatment of skin laxity of the lower face and neck in older individuals with a broad-spectrum infrared light device. J Cosmet Laser Ther. 2007;9(1):35-40.

42. Chan HH, Yu CS, Shek S, et al. A prospective, split face, single-blinded study looking at the use of an infrared device with contact cooling in the treatment of skin laxity in Asians. Lasers Surg Med. 2008;40(2):146-152.

43. Sukal SA, Geronemus RG. Thermage: the nonablative radiofrequency for rejuvenation. Clin Dermatol. 2008;26(6):602-607.

44. Sadick NS, Makino Y. Selective electro-thermolysis in aesthetic medicine: a review. Lasers Surg Med. 2004;34(2):91-97.

45. Alam M, Dover JS. Nonablative laser and light therapy: an approach to patient and device selection. Skin Therapy Lett. 2003;8(4):4-7.

46. Manuskiatti W, Wachirakaphan C, Lektrakul N, et al. Circumference reduction and cellulite treatment with a TriPollar radiofrequency device: a pilot study. J Eur Dermatol Venereol. 2009;23(7):820-827.

47. Dover JS, Zelickson B. Results of a survey of 5,700 patient monopolar radiofrequency facial skin tightening treatments: assessment of a low-energy multiple-pass technique leading to a clinical end point algorithm. Dermatol Surg. 2007;33(8):900-907.

48. Branson DF. Dermal undermining (scarification) of active rhytids and scars: enhancing the results of CO(2) laser skin resurfacing. Aesth Surg J. 1998;18(1):36-37.

49. Goldberg DJ, Whitworth J. Laser skin resurfacing with the Q-switched Nd:YAG laser. Dermatol Surg. 1997;23(10):903-906.

50. Chernoff WG. Nonexfoliating laser rejuvenation of facial rhytids. In: Keller GS, Lacombe VG, Lee PK, Watson JP, editors. Lasers in Aesthetic Surgery. New York: Thieme; 2001:139-148.

51. Zelickson B, Ross EV, Strasswimmer J. Definition and proposed mechanisms of non-invasive skin tightening. In: Alam M, Dover J, editors. Non-Surgical Skin Tightening and Lifting. Philadelphia: Elsevier; 2009:3-7.

52. Goldberg DJ. Non-ablative subsurface remodeling: clinical and histologic evaluation of a 1320-nm Nd:YAG laser. J Cutan Laser Ther. 1999;1(3):153-157.

53. Travelute AC, Carniol PJ, Hruza GJ. Laser treatment of facial vascular lesions. Facial Plast Surg. 2001;17(3):193-201.

54. Galeckas KJ, Ross EV, Uebelhoer NS. A pulsed dye laser with a 10-mm beam diameter and a pigmented lesion window for purpura-free photorejuvenation. Dermatol Surg. 2008;34(3):308-313.

55. England R. Immediate cutaneous hypersensitivity after treatment of tattoo with Nd:YAG laser: a case report and review of the literature. Ann Allergy Asthma Immunol. 2002;89:215-217.

56. Chan HH, Manstein D, Yu CS, et al. The prevalence and risk factors of post-inflammatory hyperpigmentation after fractional resurfacing in Asians. Lasers Surg Med. 2007;39(5):381-385.

57. Fisher GH, Geronemus RG. Short-term side effects of fractional photothermolysis. Dermatol Surg. 2005;31(9 Pt 2):1245-1249.

58. Lee SJ, Park SG, Kang JM, et al. Cryogen-induced arcuate shaped hyperpigmentation by dynamic cooling device. J Eur Dermatol Venereol. 2008;22(7):883-884.

59. Gaston DA, Clark DP. Facial hypertrophic scarring from pulsed dye laser. Dermatol Surg. 1998;24(5):523-525.

60. Wlotzke U, Hohenleutner U, bd-El-Raheem TA, et al. Side-effects and complications of flashlamp-pumped pulsed dye laser therapy of port-wine stains. A prospective study. Br J Dermatol. 1996;134(3):475-480.

61. Shumaker PR, England LJ, Dover JS, et al. Effect of monopolar radiofrequency treatment over soft-tissue fillers in an animal model: part 2. Lasers Surg Med. 2006;38(3):211-217.

62. Lemperle G, Rullan PP, Gauthier-Hazan N. Avoiding and treating dermal filler complications. Plast Reconstr Surg. 2006;118(3 Suppl):92S-107S.

63. Hirsch RJ, Narurkar V, Carruthers J. Management of injected hyaluronic acid induced Tyndall effects. Lasers Surg Med. 2006;38(3):202-204.

64. Effron C, Briden ME, Green BA. Enhancing cosmetic outcomes by combining superficial glycolic acid (alpha-hydroxy acid) peels with nonablative lasers, intense pulsed light, and trichloroacetic acid peels. Cutis. 2007;79(1 Suppl Combining):4-8.

65. Alster TS, Tanzi EL, Lazarus M. The use of fractional laser photothermolysis for the treatment of atrophic scars. Dermatol Surg. 2007;33(3):295-299.

66. Behroozan DS, Goldberg LH, Dai T, et al. Fractional photothermolysis for the treatment of surgical scars: a case report. J Cosmet Laser Ther. 2006;8(1):35-38.

67. Mayoral FA. Skin tightening with a combined unipolar and bipolar radiofrequency device. J Drugs Dermatol. 2007;6(2):212-215.

68. Hammes S, Greve B, Raulin C. Electro-optical synergy (ELOS) technology for nonablative skin rejuvenation: a preliminary prospective study. J Eur Dermatol Venereol. 2006;20(9):1070-1075.

69. Gold MH, Bradshaw VL, Boring MM, et al. Split-face comparison of photodynamic therapy with 5-aminolevulinic acid and intense pulsed light versus intense pulsed light alone for photodamage. Dermatol Surg. 2006;32(6):795-801.

70. Nootheti PK, Gold MH, Goldman MP. Photodynamic therapy for photorejuvenation. In: Goldman MP, editor. Photodynamic Therapy. Philadelphia: Saunders/Elsevier; 2008:125-135.

Additional Reading

Costello G. Lasers and pulsed-light devices: skin tightening (Chap 51). In Pfenninger JL, Fowler GC, editors: Pfenninger and Fowler’s Procedures for Primary Care, 3rd ed, Philadelphia: Mosby/Elsevier, 2011.

Small R. Non-ablative modalities for wrinkles. In: Small R, editor. A Practical Guide to Cosmetic Lasers. Philadelphia: Lippincott, 2012.

Stampar M. Non-ablative radiowave skin tightening (Chap 52). In Pfenninger JL, Fowler GC, editors: Pfenninger and Fowler’s Procedures for Primary Care, 3rd ed, Philadelphia: Mosby/Elsevier, 2011.

* Refers to laser and light-based technologies.

Related posts:

Tattoo Removal with Lasers Laceration Repair Suturing Techniques Procedures to Treat Benign Conditions Chemical Peels The Shave Biopsy