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Cutera will preview its Adjustable Depth Selectivity (ADS) Technology at the 67th Annual Meeting of the American Academy of Dermatology in San Francisco, March 6-10, 2009. ADS is the result of five years of clinical research conducted with in-vitro human fat cells at the Cell Culture Facility at the University of California Medical Center, San Francisco (UCSF).

The research determined fat cell survival rates following thermal exposures, which is necessary to establish treatment parameters and to make the next step in the development of new technologies for non-invasive body contouring. The two key features of this technology are the ability to selectively target and heat fat cells and to vary treatment depths within the fat.

The findings will help physicians develop new protocols for more efficacious treatment of a wide variety of patients and boost new device innovation.

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  • Filed under: LT | cellulite, New Lasers, Research
  • AAD launches today include the Aesthera’s acne system with the peer reviewed clinical paper titled “Treatment of Acne with Photopneumatic Therapy,” by Tina S. Alster MD et al. The paper studies the clinical efficacy of Photopneumatic Therapy for the treatment of mild to severe facial acne. “Our study noted greatest improvement in patients with severe acne. We are pleased with treatment outcomes, especially for severe acne,” said study co-investigator Dr. Alster. The study was performed using Aesthera’s ISOLAZ system, the only FDA cleared device for the treatment of Comedonal and Pustular Acne.

    Aesthera is launching Profusion(TM) – (Pro for Professional and Fusion is a Combination) – a skin therapy that combines the Photopneumatic light treatments with the delivery of Aesthera’s proprietary skincare to enhance skin treatment outcomes for acne, skin rejuvenation and body tightening. “Profusion’s novel mechanism has tremendous therapeutic potential for innovative new applications. We are very excited about its clinical potential,” says Vic Narurkar, MD, Chair of Dermatology at the California Pacific Medical Center (CPMC) in San Francisco, CA. “Profusion Skin Therapy is the fastest growing procedure in our practice. We routinely perform it in combination with the majority of skin treatments we offer,” he adds. New applications of the technology include body tightening and skin lightening.

    Body Tightening Technology. What’s it all about?

    It is about Photopneumatic(TM) Technology, a delivery mechanism, and the applicator that will allow for high treatment precision and focused energy delivery. The patient benefits of Aesthera’s unique solution will be fast, painless, and extremely precise treatments.

    Photopneumatic Therapy, that powers the Isolaz(TM) and Isolaz Pro(TM) system, is a proprietary combination of pneumatic energy and broad band light. Photopneumatic devices are the only laser or light based devices cleared by FDA for the treatment of inflammatory acne, comedonal acne and pustular acne. They are also cleared for the treatment of mild to moderate inflammatory acne. Photopneumatic treatments have an immediate visible impact on acne 24 – 48 hour post first treatment and are painless. Facial treatments take approximately 10 minutes, require no anesthetics or numbing creams and provide additional cosmetic benefits such as smoother appearing skin. Additionally, Photopneumatic treatments have an immediate visible impact on acne 24 – 48 hour post first treatment and are painless. Facial treatments take approximately 10 minutes, require no anesthetics or numbing creams and provide additional cosmetic benefits such as smoother appearing skin. Additionally, Photopneumatic Therapy is also cleared for the treatment of benign vascular and pigmented lesions and hair removal.

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  • Filed under: Device Review, LT | acne, Market | businesses, New Lasers
  • Cynosure has a new machine for the American Academy of Dermatology’s 67th Annual Meeting in San Francisco – Elite MPX for its Smartlipo MPX laser lipolysis workstation.

    Through the company’s patented MultiPlex(TM) technology, Elite MPX combines two wavelengths — 755nm Alexandrite and 1064 nmNd:YAG – along with Xenon Pulsed Light (XPL2) technology to create one of the industry’s most powerful workstations for vascular treatment, hair removal and skin rejuvenation. In addition, Cynosure is introducing two new intelligent delivery systems for the Smartlipo MPX workstation for laser lipolysis: SmartSense with ThermaGuide and ThermaView, the world’s first subcutaneous temperature sensing technology and thermal imaging system for Laser Body Contouring.

    Elite MPX incorporates Cynosure’s proprietary MultiPlex technology, which sequentially fires two wavelengths for more effective treatments than single-wavelength systems. A completely new software system runs the graphically enhanced Graphic User Interface, which makes its operation simple and easy.

    The workstation also features a built-in Zimmer SmartCool(R) skin cooling system that is exclusive to Cynosure. Rather than requiring a separate SmartCool device, Zimmer technology is integrated into a single compact module, saving precious office space and reducing treatment time. In addition, the Elite MPX includes eight different spot sizes, including an 18mm spot size that results in 44% more treatment area per pulse than standard spot sizes.

    “Cynosure’s Elite MPX is a powerful and versatile system that enables clinicians to customize treatments for a broad range of skin types and conditions, including sun-damaged skin, pigmented lesions, dyschromia and rosacea,” said Emil Tanghetti, M.D., Clinical Professor of Dermatology at the University of California, Davis and Director of The Center for Dermatology and Laser Surgery, Sacramento, California. “As practitioners, we are seeing a growing cultural diversity within our patient base, and I expect the Elite MPX will provide benefits across the spectrum of applications for these patients.”

    According to InMedica, the worldwide demand for hair removal, pigmented lesion removal and vascular lesion removal is expected to increase from $650 million in 2007 to $750 million by 2010.

    SmartSense with ThermaGuideis equipped with a thermal sensing cannula for measuring temperatures in the subcutaneous areas of the body. This technology allows the practitioner to set temperature thresholds to achieve targeted and controlled energy delivery for a safe and optimal clinical endpoint.

    The ThermaView thermal camera system measures skin surface temperature and provides a visual map of temperatures within the treatment area in order to provide a homogeneous delivery of thermal energy. This intelligence is integrated into the Smartlipo MPX system. As a result, thermal energy is delivered to a targeted temperature setting, helping to ensure the safe and effective treatment of the superficial layer of the surface area.

    LaserOffers.com comment

    Many people will call these advances bells and whistles. We disagree. Cynosure has come up with a lot of real technological advances rolling out this system. High capacity, large volume clinics will benefit from it, if they can afford it. All it takes to get your money back is a few hundred patients a month. Every month.

    We receive many questions regarding the use of fractional lasers for treatment of non-facial areas such as the hand. Few clinical studies have been reported in the literature documenting the efficacy of non-ablative modalities in the treatment of hands with visible photoaging conditions (search in Research).

    Laser treatment for photoaging of the hands should ideally address pigmentary alteration as well as associated skin roughness and wrinkling. Fractional non-ablative resurfacing has been previously shown to effectively treat facial rhytids and dyschromia and are currently widely used by medical practitioners and aesthetic clinics.

    About fractional non-ablative resurfacing

    Non-ablative fractional photothermolysis (nFP) produces specific thermal injury areas called microthermal treatment zones (MTZ) at specific depths in the skin. The surrounding tissue of the MTZ and the stratum corneum of the epidermis remain intact during treatment, leading to rapid healing of the injured tissue. Macroscopic wounding is not apparent. Mild to moderate erythema and edema are usually apparent for several days post-treatment, therefore there is only minimal downtime for the patient. Several treatment courses are required, which is typical of any other non-ablative laser procedures. The most commonly used is the 1,550-nm diode-pumped erbium fiber laser by Solta Medical, formerly Reliant Technologies.

    About clinical trials

    Trials are conducted by medical doctors, proficient in the laser photothermolysis field, and sponsored by grants by laser manufacturers, Solta Medical in the reviewed cases. Patients (Fitzpatrick skin phototypes I to IV) with with bilateral moderate hand photodamage were randomized to receive 5-6 treatments with the 1,550-nm diode erbium fiber laser on either the right or left hand. Treatments were performed at settings of 8 to 9 mJ/microscopic treatment zone (MTZ) and density of 2,500 microscopic treatment zones/cm2. Subjective assessments by the patients and investigator were performed for skin roughness, wrinkling, pigmentation, skin texture and overall photodamage using an improvement scale. Skin biopsies were taken at baseline and at 1 and 3 months. In addition, some histological analyses (H&E) were carried out on several individuals.

    Reported results

    The subjective assessment and physician clinical assessment at 1 and 3 months revealed a mean 51% to 75% improvement in skin pigmentation and 25% to 50% improvement in skin roughness and wrinkling. Biopsies of the skin showed increased density of dermal collagen. Patients experienced transient erythema and edema and none had scarring or other adverse effects. Histologic evaluation showed a reduction in atypical keratinocytes, improvement in rete ridge formations, increased collagen density and a reduction in solar elastosis at 6 months post-treatment.

    Fractional non-ablative resurfacing appears to be an effective and safe treatment modality for correcting both the pigmentary and the textural aspects of photoaging of non-facial anatomic areas such as the dorsum of the hands.

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  • Filed under: LT | fractional, New Lasers, Research
  • Prolonged exposure to UV-radiation induces photo-aging and a variety of visible skin changes such as lentigines, actinic keratoses and solar elastosis. Laser skin resurfacing using ablative lasers (CO(2) or Erbium:YAG) is a popular procedure to reduce these marks and improve the aesthetic appearance of photoaged facial skin . Skin resurfacing is defined as an ablation of the epidermis (the upper layers of facial skin).

    The use of pulsed or scanning Carbon Dioxide, and pulsed Erbium-YAG lasers allows the programmable and reproducible photocoagulation of thin layers of the epidermis and superficial dermis. Thermal damage depends on the type of laser and is greater with CO(2) lasers. The degree of neocollagenesis is proportional to the thermal damage and is better with CO(2) lasers. Their main indication is the correction of photoaged facial skin but they can also be used for corrective dermatology, e.g. for scars and genodermatosis.

    Ablative laser resurfacing is the most effective treatment for many conditions of the photoaged skin. Results are highly satisfactory but the technique is invasive, edema and prolonged erythema are commonand, and the patient experiences a social hindrance of about 7 to 10 days (“downtime”). Possible side effects are hyperpigmentation, hypopigmentation and, at worst, scarring.

    A new concept of laser called fractional photothermolysis has been designed to create microscopic thermal wounds to achieve skin rejuvenation without significant side-effects. The fractional techniques such as the 1,550 nm erbium fiber laser (Fraxel Laser , Reliant Technologies) are used to treat non-adjacent microzones without ablation of the epidermis. Around 25 p. 100 of the affected region is treated per session without ablation of the epidermis. Each fraction is only mini-invasive and is performed under local anesthesia. Social hindrance is reduced. Fractional laser was an attempt to bridge the gap between the ablative and nonablative laser modalities to treat the epidermal and dermal signs of skin aging. By targeting water as its chromophore, the laser induces a dense array of microscopic, columnar thermal zones of tissue injury that do not perforate or impair the function of the epidermis. The significant skin remodeling that ensues can be used to treat, with limited downtime, epidermal pigmentation, melasma, and rhytides, as well as textural abnormalities that include acne-related and surgical scars.

    LaserOffers.com comment

    Nonetheless, the results are inferior to those obtained with ablative lasers, especially regarding deep wrinkles. The treatment is costly and four sessions are usually required to treat the whole affected area. 

    The first medical lasers to be developed were continuous wave lasers that produced a continuous beam of radiation that was subsequently absorbed by a target. Although this constant laser light could effectively treat certain dermatologic conditions, its use was limited by the fact that the laser energy not only altered the target but also “spilled over” into adjacent tissues, causing unwanted collateral damage and scarring. As our understanding of the interplay between living tissue and laser physics evolved, however, so did our ability to restrict laser damage to a specific target. The concept of selective photothermolysis developed by Anderson and Parrish in 1983 gave us the tools necessary to be more precise and safer with laser energy.

    Selective photothermolysis states that a specific chromophore or target can be selectively destroyed with minimal collateral thermal tissue damage if the laser wavelength matches that absorbed by the chromophore, and if the target is exposed to the laser energy for an interval less than its thermal relaxation time. The thermal relaxation time is the time it takes a given target chromophore to lose 50% of its absorbed heat energy.

    Selective photothermolysis revolutionized laser technology and paved the way for a new generation of lasers that are designed to deliver a set wavelength for a precise duration, resulting in greater specificity and safety. The pulsed, quality Q-switched, and scanned systems are examples of such laser technology. Other so-called quasi-continuous laser systems also attempt to adhere to the theory of selective photothermolysis by limiting pulse durations from a continuous beam source through shuttering or chopping of the emitted laser beam. The usefulness of these systems is often limited owing to their high repetition rates or moderately long pulse durations, causing the target to experience the laser’s energy as if it were a continuous wave.

    Lasers emit a coherent and monochromatic light beam, whereas pulsed lights produce a polychromatic light whose bandwidth is selected by adapted filters. The skin’s chromophores are made up of water, hemoglobin, and melanin, to which must be added the exogenous pigments of tattoos. Each chromophore has its specific absorption spectrum. Lasers’ main mechanisms of action are the photothermal effect and the photomechanical effect.

    With the previously mentioned concepts in mind, the side-effect profile of a specific laser can be predicted in general terms, based on its wavelength and mode of operation. As a group, continuous wave and quasi-continuous lasers have a higher risk of scarring and textural changes through thermal buildup and heat diffusion to normal skin structures. Lasers designed on the theory of selective photothermolysis are more specific and have a lower risk profile.

    Depending on the wavelength and pulse durations delivered, pigmentary changes, epidermal cell injury, textural changes, and crusting and tissue splatter can potentially occur. It is important to remember that even the safest lasers can cause injury if used incorrectly. Repetitive or overlapping pulses, excessive energy or power settings, and improper patient selection can potentially result in a high rate of morbidity with the use of any medical laser.

    Complications might be encountered with any currently available laser systems, however, today’s laser technology is universally accepted as very safe for the patient.

    Advances in nonablative skin rejuvenation technologies have sparked a renewed interest in the cosmetic treatment of aging skin. More options exist now than ever before to reverse cutaneous changes caused by long-term exposure to sunlight. Although Caucasian skin is more prone to ultraviolet light injury, ethnic skin (typically classified as types IV to VI) also exhibits characteristic photoaging changes. Widespread belief that inevitable or irreversible textural changes or dyspigmentation occurs following laser or light-based treatments, has been challenged in recent years by new classes of devices capable of protecting the epidermis from injury during treatment. Ethnic skin represents the majority of the world’s population and yet few research studies have targeted the safety and efficacy of cosmetic skin procedures in ethnic skin. This article highlights newer advances in nonablative ethnic skin rejuvenation and evaluates their safety and efficacy.

    Defining Ethnic Skin

    In addition to grouping people of ethnic descent into classic Fitzpatrick categories of IV to VI to describe their propensity for sun reactivity, it is useful to describe how ethnic features and groups relate to one another. People of ethnic skin comprise the majority of the world’s population. These include Asians, who can be subdivided into East Asians (Chinese, Japanese, Koreans), Southeast Asians (Indonesians, Malaysians, Singaporeans, Thais, Cambodians, Vietnamese), and South Asians (Bangladeshis, Indians, Pakistanis, Sri Lankans). Those from East Asia tend to have lighter skin color, although Koreans are generally more brown-skinned than the Chinese or Japanese. Southeast Asians have brown skin color while East Asians and Southeast Asians have a Mongoloid ethnic background. South Asians are of Caucasian ethnic background but have brown to dark brown skin.

    Photorejuvenation
    Photorejuvenation is defined as the use of visible or infrared light energy sources to reverse the process of sun-induced or environmental damage to the skin. [1] Visible disruption to the overlying epidermis should not occur while trying to accomplish this in a nonablative manner. The primary objective of nonablative rejuvenation is to improve aesthetic concerns characteristic of photoaged skin, including the appearance of dyspigmentation, static fine wrinkles, coarse texture, prominent pores, and telangiectasias. In contrast, chronological skin aging results in thin skin with reduced elasticity that retains normal skin pigmentation and texture. [2] A secondary objective includes the recontouring of mild surface irregularities via subsequent dermal collagen remodeling.

    In general, all races are susceptible to photoaging. [3] However, it is clear that photoaging is delayed and less severe in patients with Fitzpatrick’s skin phototypes IV to VI. This is due to the photoprotective role of melanin. [4],[5] Published studies on photoaging in black skin have been limited to African Americans. Photoaging is more prominent in lighter-complexioned African American individuals. In addition, photoaging may not be apparent until the fifth or sixth decade of life. Clinically, the features of photoaging in African Americans can include fine wrinkling, mottled pigmentation, and dermatosis papulosa nigra. African Americans also tend to manifest signs of skin laxity with aging. This is most evident in the nasolabial folds and jaws. [6] Most studies on the treatment of photorejuvenation in ethnic skin utilize nonablative technologies that will be discussed in this paper.

    Fractional devices

    Fractional photothermolysis (Fraxel SR, Reliant Lasers, Palo Alto, CA, USA) is a novel nonablative erbium:glass (1500 nm) laser treatment for facial rejuvenation. [7] It is also used for the treatment of melasma and acneiform scarring. [8] Fractional photothermolysis is performed with a midinfrared laser, which creates microscopic columns of thermal injury. These zones of thermal injury, termed microthermal zones (MTZs), have a diameter that is energy-dependent and ranges from 100 to 160 μm. The depth of penetration ranges from 300 to 700 μm at the energies commonly used for facial rejuvenation (8-12 mJ/MTZ).[9] Relative epidermal and follicular structure sparing are responsible for rapid recovery without prolonged downtime. Melanin is not at risk of selective, targeted destruction; therefore, fractional resurfacing has been used successfully in patients with skin of color. Kono et al . [10] have described the use of the Fraxel in 35 type IV and V Asian patients and concluded that increased density was more likely to produce swelling, redness, and hyperpigmentation when compared to increased energy. In this study, the authors concluded that patient satisfaction is significantly higher when their skin is treated with high fluences than when treated with high densities. They concluded that fractional photorejuvenation can be safe and effective in darker ethnic skin types. [10]

    Prior studies using fractional photothermolysis have demonstrated its effectiveness in the treatment of photodamaged skin; however, only preliminary results have been reported regarding its use for scars. Given the rapid healing associated with this procedure and its known effect on collagen remodeling, this study was designed to prospectively evaluate the use of fractional photothermolysis in the treatment of atrophic scars. Fifty-three patients (skin phototypes I-V) with mild-to-moderate atrophic facial acne scars received monthly treatment with a 1550 nm erbium-doped fiber laser (Fraxel, Reliant Technologies Inc., San Diego, CA). Clinical response to the treatment was determined by two independent assessors at each treatment visit and six months after the final treatment session, by using a quartile grading scale. Side effects and patient satisfaction were monitored at each follow-up visit. Ninety-one per cent of the patients had at least 25-50% improvement after a single treatment, whereas 87% of the patients receiving three treatments demonstrated at least 51-75% improvement in the appearance of their scars. Moreover, age, sex, and skin phototype also did not significantly affect the observed clinical responses. Hence, it was concluded that fraxel procedures were effective in acne scar treatment for skin of color. [11]

    532 nm Laser

    Although not a prominent feature of ethnic skin, treatment of the pigmented and telangiectatic component of photoaging has been reported in ethnic skin. [12],[13] Rashid and colleagues reported the use of a quasicontinuous wave 532 nm laser in the treatment of lentigines in type IV skin patients. [13] They showed 50% improvement in lesion clearance, with a 10% incidence of hyperpigmentation and 25% incidence of hypopigmentation after multiple treatments. These side effects abated after two to six months. Lee reported 150 patients with skin types I to V who were treated in multiple sessions with 532 nm (4 mm spot, 6-15 J/cm 2 , 30-50 millisecond pulse duration), 1064 nm (10 mm spot, 24-30 J/cm 2 , 30-65 millisecond pulse duration), or a combination of both. [11] Sapphire-tipped contact cooling was utilized. Improvement in erythema, texture, pigmentation, and rhytids was reported in both study arms but was highest in the combination group. An incidence of 5% postinflammatory hyperpigmentation was reported in patients with types III and IV skin treated with the 532 nm laser alone, which resolved after 4-6 weeks. [12] The use of conservative settings to achieve the desired results is prudent. Following these guidelines, the clinician is most likely to achieve a favorable result with the least unwanted side effects. Test spots are necessary to assess the initial patient response and decrease the risk of hypopigmentation, which is often very difficult to treat.

    1064 nm Laser

    Long-pulsed and Q-switched 1064 nm lasers target melanin as well as hemoglobin and water. Although safer for darker skin, there is a diffuse heating of dermal tissue owing to the deep, penetrating nature of 1064 nm with a typical dispersion depth of 5-10 mm. [1] One study has shown evidence of improvement with a Q-switched 1064 nm laser for nonablative treatment in type IV skin. [13] Sun-damaged 4 cm × 4 cm areas of infraauricular skin were exposed to a 1064 nm Q-switched Nd:YAG laser at a fluence of 7 J/cm 2 and a 3 mm spot size. Two laser passes with a 10-20% overlap, were used on all subjects in an attempt to promote petechiae as the visible end point. Petrolatum dressings were applied for a week after treatment. Three millimeter punch biopsy specimens were taken from each subject before treatment. Photographs were taken of the biopsy sites. Three months after the last treatment, another biopsy specimen was taken from a different previously treated area. Histological specimens were evaluated blindly by a board-certified dermatopathologist. Four out of six skin biopsy specimens obtained three months after the last laser treatment, showed mild fibrosis with histological improvement in pretreatment solar elastosis. There was a mildly thickened, upper papillary collagen zone, with an improvement in the organization of collagen fibrils. The remaining two specimens showed no changes. Clinically, none of the treated, nonbiopsied areas showed any evidence of pigmentary changes or scarring. [13]

    Another study utilized the 1064nm Nd:YAG (Laser genesis) for the rejuvenation of facial skin of types I-V. Patients’ and masked physician assessment demonstrated overall improvement. Specific improvement was also demonstrated in coarse wrinkles and skin laxity. No adverse events were noted in this study. [14] Studies have all confirmed the effectiveness and low risk of complication associated with Nd:YAG for rejuvenation in skin of color.

    Intense Pulsed Light

    Another device for photorejuvenation of ethnic skin is Intense Pulsed Light (IPL). IPL is produced by a noncoherent flashlamp-pumped light source that is capable of emitting light from 500 to 1200 nm. [15] The use of cutoff filters allows the elimination of some of the shorter wavelengths of the visible light spectrum to limit melanin absorption. Different pulse widths can be chosen so that appropriate parameters match the thermal relaxation times of the targets. [16] Cooling of the epidermis is achieved with contact cooling in the device head or with external cooling devices.

    Negishi and colleagues were among the first to investigate the use of IPL in types IV and V Japanese patients using pulsed light devices. They applied a thin layer of ice-cold gel and they utilized a 550 nm cutoff filter. Settings were 28 to 32 J/cm 2 and 2.5-4.0 and 4.0-5.0 millisecond pulse durations. Excellent results were reported in 73 out of 97 patients. [17],[18] No evidence of dyspigmentation was reported in either series. Negishi and colleagues have also employed UV photography to identify and treat subclinical epidermal hyperpigmentation with IPL in skin of color. [19] Although IPL has been utilized with success in skin of color, treatment of such patients should utilize conservative settings to achieve a favorable result with the least unwanted side effects.

    Light-emitting diode (LED)

    Apart from the light- and laser-based devices described above, three newly described nonablative technologies have been used for treatment in ethnic skin types. Light Emitting Diodes (LEDs) represent the latest advancement in visible spectrum, monochromatic light therapy for photoaged skin. Typically, LEDs in devices are arrayed in panels, and each emits visible light in a ±10-20 nm band around the dominant emitted wavelength. Energy output is less than 25 W, representing a fluence of about 0.1 J/cm 2 . The Gentlewaves LED device (Light Biosciences, Virginia Beach, VA, USA) recently received approval from the US Food and Drug Administration for the treatment of periorbital wrinkling. [20] In brief, this device is thought to act by targeted stimulation of fibroblastic mitochondrial metabolic activity, concomitant upregulation of procollagen, and downregulation of matrix metalloproteinase I. [21],[22]

    Radiofrequency (RF)

    Radiofrequency (RF) is an electromagnetic radiation in the frequency range of 3 kHz to 300 GHz. The primary effects of RF energy on living tissue are considered to be thermal. The main goal of these new frequency-based devices is to heat specific layers of the skin. Directed use of RF can induce dermal heating and cause collagen degeneration. Wound healing mechanisms promote the remodeling of collagen and wound contraction, which ultimately enhances the appearance of mild to moderate skin laxity. Preliminary studies with one device (Thermacool, Thermage Inc, Hayward, CA, USA) have reported efficacy in the treatment of laxity involving the periorbital area and jowls. [23] As RF energy is not dependent on specific chromophore interaction, epidermal melanin is not at risk of destruction and treatment of all skin types is possible.

    Kushikata et al. [24] reported the use of RF in a series of 85 Asian patients of dark skin types and concluded that RF treatment was very satisfactory for skin tightening in Asian facial skin. RF appears to be a promising means of photorejuvenation in ethnic skin.

    Infrared Tightening

    Improvement of facial and cervical skin laxity has been difficult to achieve without surgical procedures. A device called the Titan (Cutera, Inc., Brisbane, California) uses infrared (IR) light to volumetrically heat the dermis. It is designed to thermally induce collagen contraction with subsequent collagen remodeling and neocollagen synthesis. The epidermis is protected via pre-, parallel, and posttreatment cooling. No anesthesia is necessary as there is minimal to no discomfort during the procedure. Improvements in skin laxity and facial and neck contours have been achieved with this device, although results can vary. This variation may be caused by patient variability and differences in technique. [25]

    Few studies have addressed the efficacy and safety of infrared use in darker skin, however Chua et al. investigated the use of IR on 21 patients of Fitzpatrick skin types IV and V. Eighty-six per cent of the patients had improvement as measured by the physician’s assessment at their six months’ follow-up visit. Hence, Chau et al. concluded that direct application of infrared light with epidermal cooling is effective in achieving gradual, mild-to-moderate clinical improvement in the treatment of facial and neck skin laxity. The procedure is associated with minimal downtime and is safe for use in darker skin types IV and V. [26]

    Plasma skin regeneration (PSR) technology

    Plasma is the fourth state of matter acquired by ionizing a gas. One example of this is the light we see with lightning. The electricity (energy) discharged from the clouds to the earth heats up the air (gas) and converts it into plasma. [27] A basic understanding of skin structure is required to understand how PSR works. Briefly, skin consists of three layers: the epidermis (uppermost layer), dermis (middle layer) and subcutis (lower fat layer). The epidermis contains pigment-producing cells called melanocytes, which are responsible for skin coloring. The dermis is made up of collagen and elastin fibres that provide skin with strength, toughness, elasticity and pliability. The appearance and characteristics of skin change as the body ages. The epidermis becomes thinner so that blemishes become more visible, and collagen in the dermis is gradually lost, which contributes to the formation of facial lines, sagging skin and wrinkles. [28]

    To date, there are five anti-aging treatment regimens – PSR 1, PSR 2, PSR 3, PSR 2/3 combination and a fifth newly FDA approved one. A particular regimen is chosen according to the severity of the problem being treated and the recovery time available. The fifth treatment is a new FDA-approved, anti-aging procedure for treating nonfacial areas of the body. All protocols could be used for lines; however, higher energy treatments are needed for skin tightening. Studies have shown that the thermal energy at 1.0 and 2.0 J was limited to the epidermis and dermoepidermal junction. At 3.0 and 4.0 J, the thermal injury reached the papillary dermis. PSR 1 protocol uses a low-energy treatment spaced three weeks apart. PSR 2 uses a single high pass 3.0-4.0 J energy treatment with a recovery time of 5-7 days. PSR 3 uses two high-energy passes (3.0-4.0 J) with a recovery period of 6-10 days. A fourth protocol uses a combination of PSR 2 and PSR 3 and the fifth one uses very low energy (0.5 J) in a series of three treatments at three-week intervals. [29] Few studies have been carried out on subjects so far; however, Kilmer, [30] Poter, [31] Benstein [32] and Bogle [33] have all demonstrated the low risk and efficacy of using such technology in all skin types.

    Summary

    In conclusion, laser procedures in darker skinned patients are challenging but can be successfully achieved if certain treatment guidelines are followed. Discussion of risks and patients’ expectations are essential in treating the darker-skinned patient population. Pre- and postlaser cooling can be helpful to minimize side effects and improve patients’ comfort. This is especially true with laser hair removal. Photorejuvenation can be successfully achieved with low risk when appropriate settings are used. Fractional technology has increased treatment options for rhytides and atrophic scars. Although there are few studies on LED treatments in skin of color, this type of treatment can be used either as a primary or adjunctive treatment modality with apparently low risk. The 532 nm laser has proved to be risky in skin of color and conservative guidelines should be followed when using it. On the other hand, the 1064 nm laser may offer greater safety when treating ethnic skin albeit still risky in type VI skin. The IPL is a safe option for treating skin of color although it is advisable to limit its use for skin types V and VI. Finally, radiofrequency and newer tightening technologies are safe and highly reliable to use for ethnic skin. However, it is prudent to use conservative settings to achieve the desired results when treating darker skinned patients. The clinician is most likely to achieve a favorable result with the least unwanted side effects if these guidelines are followed.


    References

    1. Weiss RA, McDaniel DH, Geronemus RG. Review of nonablative photorejuvenation: Reversal of the aging effects of the sun and environmental damage using laser and light sources. Semin Cutan Med Surg 2003;22:93-106.
    2. Kim KH, Geronemus RG. Nonablative laser and light therapies for skin rejuvenation. Arch Facial Plast Surg 2004;26:186-95.
    3. Griffiths CE, Goldfarb MT, Finkel LJ, Roulia V, Bonawitz M, Hamilton TA, et al. Topical tretinoin (retinoic acid) treatment of hyperpigmented lesions associated with photoaging in Chinese and Japanese patients: a vehicle-controlled trial. J Am Acad Dermatol 1994;30:76-84. [PUBMED]
    4. Kligman AM. Solar elastosis in relation to pigmentation. In : Fitzpatrick TB, Pathak MA, editors. Sunlight and man. Toyko: University of Toyko Press; 1974. p. 157-63.
    5. Pathak MA. The role of natural photoprotective agents in human skin. In : Fitzpatrick TB, Pathak MA, editors. Sunlight and man. Tokyo: University of Tokyo Press; 1974.
    6. Matory WE. Skin care. In : Matory WE, editor. Ethinic considerations in facial aesthetic surgery. Philadelphia: Lippincott; 1998. p. 100.
    7. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional photothermolysis: A new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med 2004;34:426-38. [PUBMED]
    8. Fisher GH, Geronemus RG Short-term side effects of fractional photothermolysis. Dermatol Surg 2005;31:1245-9.
    9. Fitzpatrick R, Geronemus R, Goldberg D, Kaminer M, Kilmer S, Ruiz-Esparza J. Multicenter study of noninvasive radiofrequency for periorbital tissue tightening. Lasers Surg Med 2003;33:232-42. [PUBMED]
    10. Kono T, Chan HH, Groff WF, Manstein D, Sakurai H, Takeuchi M, et al. Prospective direct comparison study of fractional resurfacing using different fluences and densities for skin rejuvenation in Asians. Lasers Surg Med 2007;39:311-4. [PUBMED]
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