Ablative versus nonablative; laser versus needling.
Here is an evaluation of many current techniques
The beauty, texture, and color of skin have invoked passion, inspired poets, caused racial segregation, dictated fashion—and generated one of the most lucrative industries in the world. The psychosocial aspect of aging skin is exemplified by the media, actors, models, and peer pressure. “Ideal beauty” is a sought-after commodity for young and old—men and women alike—and is underscored by the fact that skin-rejuvenating procedures increased by 300% from 2003 to 2004.1
People are becoming more educated about the various skin procedures and are less inclined to take risks. Surgery can restructure a sagging face, but it does not rejuvenate the skin. Patients are also reluctant to spend a significant amount of downtime recuperating. This reluctance has spawned the development of many topical and nonablative techniques that all work by damaging the skin to cause fibrosis that leads to skin tightening.
How, then, is a patient or practitioner to choose among the numerous less-invasive and nonablative procedures? Many procedures are old, tried, and tested—but not without risk. Some are new and offer hope, but do not have the long-term clinical data necessary for the physician and patient to feel secure.
The ideal procedure would provide tighter skin with diminished fine wrinkles, the disappearance of brown spots and telangiectasias, and smaller pores—with little to no downtime, and without changing the patient’s skin pigmentation.
Nonablative photorejuvenation consists of two major components: removal of the epidermal signs of photodamage, such as mottled pigmentation (lentigines and ephelides) and telangiectasias; and nonablative dermal remodeling, as defined by Weiss.2,3 Nonablative procedures have the advantages of minimal downtime, with only mild pinkness, because the epidermis is not removed or vaporized.
The disadvantages are that they require multiple treatments, skin-laxity and deep-wrinkle improvements are variable, repeat procedures—sometimes as much as a facelift—are costly, and the results are not immediate: The final result may not be seen until as much as 1 year has passed.
What are the nonablative skin-rejuvenating and skin-tightening options?
Radiofrequency (RF) energy is delivered as electromagnetic radiation that interacts with tissue to produce thermal effects. RF technology is available in monopolar and bipolar modes, and can be combined with intense pulsed-light (IPL) systems. RF is indicated to treat superficial pigmented lesions, including telangiectasias, rosacea, fine lines, wrinkles, poikilodermas, and angiomas.
Light is absorbed by chromophores to diminish superficial pigmented lesions, and the heat generated produces results at the epidermal and deep dermal levels. Light induces higher temperatures in the epidermis, and the combination of light and RF penetrates the deep dermis. The combination of controllable energies that reach multiple levels makes it possible to treat fine lines at the surface and deeper dermal wrinkles.
Sadick et al reported their findings from using IPL and bipolar RF energy on 108 consecutive patients, each of whom received five full-face treatments every 3 weeks.4 The results were assessed by double-blind photographic evaluation by physicians and by patient-satisfaction scales. All skin parameters were improved, as shown in the Table below, and complications and side effects were minimal.
RF also extends the use of energy sources to a greater range of skin types. In a study done at Tokyo Women’s Medical University, the efficacy and clinical effect of RF were assessed in 85 females.5 They were enrolled for the study of treatment for nasolabial folds, sagging jowls, and marionette lines; the 6-month follow-up reported very satisfactory results.
These studies offer only 6-month results, so the question is: Does the patient enjoy a few months of wrinkle reduction due to edema, or are the results longer lasting—especially in the study that looked at the decrease in sagging skin? Is this enough for the consumer, considering the money spent?
The 1064-nm Nd:YAG Laser
This laser uses energy in the near- and mid-IR wavelengths in the electromagnetic-radiation spectrum, with micropulse duration. In this range, the radiation is minimally “attracted” to melanin; therefore, patients of all Fitzpatrick skin types can be treated with low risk. By extending the wavelength range, energy can be delivered to the dermis to treat pore size, texture, and fine lines.
The success in terms of tolerability—and, hence, efficacy—of this procedure is enhanced by adding a skin-cooling device. Anesthesia requirements are minimal, and fewer patients require pharmacological intervention.
In a Spanish study, 10 patients with facial wrinkles were treated with the long-pulsed 1064-nm Nd:YAG laser, with a spot size of 5 mm diameter, an energy density of 13 joules per square centimeter (J/cm2), an exposure time per pulse of 300 microseconds, and a repetition rate of 7 hertz.6 All patients had a total of three treatments, once every 2 weeks.
At 6 months after the final treatment session, the patients’ subjective satisfaction index was maintained at 40%; it had peaked at 50% 2 months after the final session. The greatest effect for facial wrinkles was seen 2 months after the final treatment. Effects were still visible at the 6-month period, but showed a tendency to wear off. Maintenance treatments were required to achieve good patient satisfaction.
Friedman et al presented photographic data from an optical system that produces 3-D measurements of skin surfaces.7 Two patients, one with acne scarring and one with rhytides, had been treated with a 1064-nm Q-switched Nd:YAG laser in five treatment sessions, spaced at monthly intervals. At the 6-month follow-up, objective skin roughness had decreased 26% in the patient with rhytides and 33% in the patient with acne scarring.3,7
Such attempts to quantify subtle differences in skin texture are important, because they provide an objective means for analyzing treatment efficacy. However, if nonablative laser treatment of rhytides and scars can be validated only by a photographic imaging technique, there is cause for concern. Can the results be appreciated by the naked eye?
Intense Pulsed Light
IPL devices differ from lasers in that they emit noncoherent light in a broad wavelength spectrum (1100 to 1800 nm). They tighten skin by contracting collagen. Their main advantage is that they are less painful than other devices used for similar applications, but four or more treatments are generally required.
IPL sources have been reported to show excellent histological findings by altering dermal collagen structure—but do they always coincide with the clinical results and patient-satisfaction index?
Bhatia and Arndt compared aminolevulinic acid (ALA)–IPL to IPL alone in a prospective, randomized, split-face study.8 Overall investigator and patient assessment was that ALA–IPL was superior to IPL alone.
In another study, the IPL system was applied with the yellow (570-nm) cutoff filter, 30 J/cm2, single pulse, followed by the Nd: YAG laser at 120 J/cm2, double pulse (7 milliseconds per pulse with 20 milliseconds between pulses) on the wrinkled areas only.9 Three sessions were given at monthly intervals. The control group was treated only with IPL, using the same parameters and number of sessions. Histological specimens were taken from four consenting patients from each group. The combined treatment showed a greater improvement in histological tissue conditions, and fewer ectatic blood vessels were seen in the deeper dermis.
The addition of ALA, the 1064-nm Nd:YAG laser, and even RF to the IPL regimen for nonablative skin rejuvenation gives superior histological and clinical results, in contrast to the IPL alone. Results from numerous clinical and histological studies indicate that these technologies are successful, but do not compare in efficacy to ablative skin resurfacing.10
Figures 1 and 2 demonstrate the use of IPL devices.
The Light-Emitting Diode (LED)
The LED emits a long wavelength not absorbed by melanin, so it does not cause hypopigmentation. The photochemical absorption stimulates collagen and causes inflammation that leads to tightening of the dermis.
The literature promoting these claims is limited and often questionable; however, dermatologists who own these instruments often report high demand for their use, high customer satisfaction, and a sense that they deliver on their promises— despite a lack of clinical evidence from properly controlled studies.11
Minimally Ablative Techniques
Fractional resurfacing is performed with an innovative fiber-erbium laser, driven by a computer-generated pattern that produces fractional photothermolysis for treating sun damage, acne, and facial rhytides. It can treat all skin types.
The wound-healing response differs from other techniques in that it spares areas of epidermal tissue between treatment zones that contain viable cells, including epidermal stem cells and transient-amplifying cell populations. This ensures rapid re-epithelialization and gives this procedure an advantage over other resurfacing techniques.
Fractional resurfacing is still in the early stages of development. It currently requires at least four sessions, and it can be done in the physician’s office. It has the added benefit of treating therapy-resistant melasma.
In one study, 10 female patients of Fitzpatrick skin types III–V who were unresponsive to previous treatments were treated four to six times at 1- to 2-week intervals.12 Two physicians evaluated the photographs and found that 60% of patients achieved 75% to 100% clearing, whereas 30% had less than 25% improvement. Both physicians concurred on the patients’ evaluations in all but one case. More studies and long-term follow-up are needed to completely evaluate the results.
The Er:YAG laser heats the dermis and tightens wrinkles, but causes oozing, and therefore considerable downtime. Goldman states that, in his experience with more than 20 different lasers, the Er:YAG laser is best for skin tightening with minimal downtime, and that IPL is best for correcting pigmentation and telangiectasias.1
Most experts agree on the fundamentals of good ablative laser surgery, and few controversial points have emerged. Some experts prefer using short-pulsed carbon dioxide (CO2) lasers, especially for deeper rhytides and scars, whereas others opt for erbium or blended lasers for fine lines and more superficial scars. But all seem to agree that the instruments are comparable when used to achieve the same limited depth of thermal injury.
In plasma resurfacing, radiofrequency heats nitrogen gas with 1 to 4 J of energy and is not chromophore-dependent. The heat causes thermal modification of the fibroblasts, and all skin types can be treated. It is targeted at actinic keratosis, wrinkles, pigmentation, skin tone, and acne scarring.
This technology offers superficial skin ablation while minimizing thermal damage. The results appear to be similar to CO2 laser resurfacing, but with shorter recovery times. In early trials, patients re-epithelialized in 5 to 8 days and had no scarring or pigmentary alteration. Tremblay comments that, “Plasma skin resurfacing using ablative energy parameters results in superior periorbital skin rejuvenation at the cost of modest recovery time compared to CO2 laser resurfacing.”8
Medical needling, or percutaneous collagen-induction therapy, lends itself to rejuvenation through collagen production via multiple miniscule pin-prick wounds to the skin. There is no thermal injury. As tens of thousands of fine pricks are placed closely to one another, a field effect that promotes the normal post-traumatic release of growth factors and infiltration of fibroblasts is achieved by the three phases of wound healing.
Phase 1 consists of inflammation, and starts immediately after the injury. Phase 2 begins with proliferation and tissue formation; it starts after 5 days and lasts up to 8 weeks. Phase 3 promotes tissue remodeling, in which collagen type 3 is laid down in the upper dermis and gradually replaced with collagen type 1 over 1 year, increasing tensile strength.
The effects of this procedure are enhanced by adequately preparing the skin with vitamin A. Postprocedural application of high doses of vitamins A and C drives the healing process and the normal collagen production. The advantage of this procedure is that some of the epidermal cells are spared, like fractional photothermolysis, and this reduces the side-effect profile, making it a suitable procedure for all skin types.
Needling is suitable for restoring skin tightness in the early stages of aging.13 The neck, arms, breasts, abdomen, and thighs can be safely treated. The procedure shows promise for acne and hypertrophic burn scars. Postoperatively, the patient is very swollen and erythematous for 3 to 5 days, but not as red as with dermabrasion, and there is less downtime.
There is also no hypopigmentation or demarcation, so small areas can be treated—making it an ideal procedure in combination with other surgeries. However, more clinical data need to be published for this procedure to become widely accepted.
See Figures 3 and 4 for examples of the use of medical needling.
Which Is Best?
It is common knowledge that ablative techniques such as the CO2 laser and phenol peels can accomplish smooth, tight, flawless skin that lasts for many years—but not without consequences. The downtime required for ablative techniques in today’s busy world may not be suitable for some patients.
Nonablative techniques have a definite place in skin rejuvenation, but patients’ expectations must be assayed. Three months after laser treatment, a critical eye can see the difference—but does this last, or is it due to edema and inflammation?
Successful skin rejuvenation requires multiple techniques, and a good aesthetic practice should offer several different treatment modalities. The key to a happy practice and patient is not to overpromise—and never use the term “permanent.” The physician and patient should communicate well to learn what each expects and how much downtime can be tolerated.
Showing before-and-after pictures of patients (good and bad results, at 3 months and 1 year) and photos during the healing phase of some of the ablative procedures will make for a more informed and happier patient. Questions to ask are: Does the patient want more homogenous skin texture and color? Or does he or she want a decrease in wrinkles, a reduction in skin laxity, or a combination of these? No one modality can accomplish all of this unless it is invasive, so compromises in treatments must be made. PSP
Deirdre S. Leake, MD, is a facial plastic surgeon in private practice at the North Florida Center for Otolaryngology and Facial Plastic and Reconstructive Surgery, St Augustine, Fla. She received her medical degree at the University of Tennessee, Knoxville, and her residency in otolaryngology and head and neck surgery at the University of Rochester, NY. She then did a fellowship in facial plastic and reconstructive surgery at the University of Michigan, Ann Arbor. She can be contacted at (904) 823-8823.
Janine L. Ellenberger, MD, is a general practitioner in private practice at The Treatment Rooms, Berkshire, United Kingdom. She received her medical degree at the University of the Orange Free State, Bloemfontein, South Africa, and did her internship at the JG Strydom Hospital in Johannesburg. She did a fellowship in obstetrics–gynecology at the University of Stellenbosch, Tygerburg, South Africa. She can be reached at (786) 543-6989 or [email protected].
1. Goldman MP. Cutting through the confusion of all of the non-invasive and invasive lasers currently on the market and what we are currently using in our practice. Paper presented at: Fall Meeting of the American Association of Facial Plastic Surgeons; September 22–25, 2005; Los Angeles, Calif.
2. 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.
3. Lipper GM. American Society for Laser Medicine and Surgery 2002: Shedding light. Available at: http://www.medscape.com/viewarticle/436024 Accessed February 9, 2006.
4. Sadick NS, Alexiades-Armenakas M, Bitter P Jr, Hruza G, Mulholland RS. Enhanced full-face skin rejuvenation using synchronous intense pulsed optical and conducted bipolar radiofrequency energy (ELOS): Introducing selective radiophotothermolysis. J Drugs Dermatol. 2005;4: 181–186.
5. Kushikata N, Negishi K, Tezuka Y, Takeuchi K, Wakamatsu S. Non-ablative skin tightening with radiofrequency in Asian skin. Laser Surg Med. 2005;36:92–97.
6. Trelles MA, Alvarez X, Martin-Vazquez MJ, et al. Assessment of the efficacy of nonablative long-pulsed 1064-nm Nd:YAG laser treatment of wrinkles compared at 2, 4, and 6 months. Facial Plast Surg. 2005;21: 145–153.
7. Friedman PM, Jih MH, Skover GR, Payonk GS, Kimyai-Asadi A, Geronemus RG. Treatment of atrophic facial acne scars with the 1064-nm Q-switched Nd:YAG laser: Six-month follow-up study. Arch Dermatol. 2004;140: 1337–1341.
8. Moody BR. Cosmetic dermatology highlights. Available at: http://www.medscape.com/viewarticle/472160 Accessed February 9, 2006.
9. Trelles M, Allones, I, Vélez M, Mordon S. Nd: YAG combined with IPL treatment improves results in non-ablative photorejuvenation. J Cosmetic Laser Ther. 2004;6:69–78.
10. Grema H, Raulin C, Greve B. Skin rejuvenation by non-ablative laser and light systems. Hautarzt. 2002;53:385–392.
11. Abramovits W, Arrazola P, Gupta AK. Light emitting diode-based therapy. Available at: http://www.medscape.com/viewarticle/499713 Accessed February 10, 2006.
12. Rokhsar CK, Fitzpatrick RE. The treatment of melasma with fractional photothermolysis: A pilot study. Dermatol Surg. 2005;31: 1645–1650.
13. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin N Am 2005;17:51–63.