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Nonsurgical skin tightening modalities
Practice Forum
Panel Discussion
Nonsurgical Skin Tightening Modalities A. Jay Burns, MD; Jeffrey Dover, MD; Richard O. Gregory, MD; Brian Zelickson, MD Dr. Burns is Assistant Professor at the University of Texas Southwestern Medical Center, Dallas, TX. Dr. Dover is Associate Clinical Professor, Department of Dermatology, Yale University School of Medicine, New Haven, CT, and Adjunct Professor of Medicine (Dermatology) at Dartmouth College Medical School, Hanover, NH. Dr. Gregory is in private practice in Celebration, FL. Dr. Zelickson is Adjunct Associate Professor, Department of Dermatology, the University of Minnesota Medical School, Minneapolis, MN.
Dr. Burns: The first patient is a 67-year-old woman who has refused surgical correction (Figure 1). Her priority is to correct the looseness under her neck and jaw line, as well as to improve her general skin condition, which has been compromised by acne damage over her cheeks and forehead. She would also like the redness in her skin addressed. Dr. Dover, how would you approach treating this woman? How would you manage her expectations, and what could you realistically offer? Dr. Dover: I think what she really needs is a face lift, even though I know she is resistant. She has a heavy face with a lot of sagging and extreme neck A. Jay Burns, MD elasticity. Unless she has a surgical correction, she will never get dramatic improvement in her lower face. You could, however, use skin tightening devices and get some modest improvement. I have actually been pleasantly surprised that people with a significant degree of sagging do sometimes get Richard O. Gregory, MD noticeable tightening, but it is never dramatic. However, in patients such as this, I typically do not recommend nonsurgical skin tightening because the cost and time are not usually worth it. A far less significant issue, the redness, could be improved with a variety of devices, such as pulsed dye laser, a pulsed potassium-titanyl-phosphate (KTP) green light laser, or intense pulsed light (IPL). The latter two would also help with her pigmentation. But her big issue is sagging, which is pronounced.
Dr. Burns: Dr. Gregory, what would you suggest for this patient? Dr. Gregory: I agree with Dr. Dover’s recommendation for face lift. Although we understand what we can realistically achieve with nonsurgical treatment, I suspect that her expectations are too high. Her face has early basal cells or heavy actinic keratosis. I would consider using the CO2 laser because I believe I could get rid of all of that actinic damage with it. I have also been able to correct some pigmentation disorders and tighten skin a bit. I think she would be very likely to get some hypopigmentation, but her neck Jeffrey Dover, MD is very pale to start with, so I don’t think this would create a large discrepancy between her face and neck. Dr. Burns: Why do you think that she would most likely get some hypopigmentation?
Brian Zelickson, MD
Dr. Gregory: She is already very pale around her mouth and eyes. Her skin is generally very pale, with marked weathering.
Dr. Burns: That is a good point because a lot of people are confused about who gets hypopigmentation. Interestingly, type I and type II pale individuals are the prime candidates for development of hypopigmentation. Early on in the resurfacing experience, we worried about hypopigmentation in darker type IV and V skin, but this is fortunately very rare. Dr. Zelickson, do you have anything to add?
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Dr. Gregory: I think she would be a great candidate for some fractionated laser treatment because it would even out the skin color of the lentigos, brown pigmentation, and hypopigmentation, as well as improve the texture of her skin and acne scarring. Dr. Burns: Dr. Zelickson, do you agree with this approach? Dr. Zelickson: Yes, I think she is a perfect candidate. Dr. Burns: What could she expect out of the fractionated treatment? Dr. Zelickson: It will take a series of 4 to 6 treatments. I would try to lighten the skin surrounding the hypopigmented areas, rather than try to repigment those areas. Usually, I tell patients to expect 20% to 40% improvement in skin texture. After I complete the series of treatments, if a patient goes out and gets a lot of sun exposure, the sponging and the pigmentation can return, so I advise patients to be very vigilant with sun protection. Dr. Burns: Dr. Dover, would you like to add something?
Figure 1. This 67-year-old woman has refused surgical correction but is concerned with looseness under her neck and jowls, as well as the general actinic damage on her cheeks and forehead. She would also like the redness addressed.
Dr. Zelickson: We know that she is adamantly opposed to surgery but wants treatment. I think I might improve her quite a bit with fillers. I have been successful with patients like this in whom you can see the lateral jowls. So for this patient, assuming she did not have unrealistic expectations, I might recommend a nonablative tightening procedure combined with some type of filler. Dr. Burns: The next patient is a 47-year-old woman with a history of acne (Figure 2). I am not sure the photograph shows this well. Her acne scarring is moderate at best, not terrible, but she is left with some dyspigmentation of the left cheek and diffuse dyschromia. She is interested in improving her skin overall. Dr. Gregory, what would be your preferred treatment for this patient?
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Dr. Dover: She is actually a very good candidate for fractional laser treatment. I have been more and more impressed over the last 6 months with results in acne scarring from fractional resurfacing. Now that we have the experience from treating several hundred patients, I can report that, after 6 treatments, results in the treatment of acne scarring are as good as those achieved with CO2 laser resurfacing with far less risk. In fact, the results with fractional resurfacing may be slightly better. The benefit here would be for the hyperpigmentation and the texture. IPL is also an option if you wanted to improve color only and were far less bothered by texture. IPL may be appropriate for someone who wants to limit the cost or downtime of fractional resurfacing, which on average produces 3 days of redness and swelling. She would actually get better results in terms of pigmentary improvement with IPL than with the fractional laser resurfacing, but she would not get the same textural improvement. Dr. Burns: One of the mechanisms is that the improvement in hypopigmented areas would decrease the apparent difference between the varying areas of pigmentation. I have heard experts experienced with the Fraxel device (Reliant Technologies, Mountain View, CA) state strong-
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Dr. Dover: The only thing I would add is that this concept remains unproven. We are probably lightening pigment and making the patchy things blend better. Dr. Burns: The third patient is a 57-year-old woman who is concerned about dyschromia, lines around her eyes, and crow’s-feet (Figure 3). On the oblique view, you can also see dyschromia out towards her jaw. After discussing laser resurfacing with her, it became clear that she does not want the associated downtime. Dr. Zelickson, what would you suggest to her? Dr. Zelickson: It sounds like this patient is primarily interested in improving her pigmentation. I could certainly get good results with a series of IPL treatments and Botox along the crow’s-feet. That would yield a very good response. Other resurfacing techniques would also be appropriate. One could do a single pass of the CO2 or light erbium laser but, again, there is a little more downtime with that, and the lines around the crow’s-feet would still need to be treated with Botox. Another option is the Fraxel device. The fractionated devices would take a series of treatments, but you would expect modest improvement in the lines around the cheeks and, again, combine that with Botox. Dr. Burns: If you chose to use the Fraxel device, what would be your expectations for the patient? Figure 2. This 47-year-old woman with a history of acne is left with hypopigmentation of the left cheek and diffuse dyschromia.
ly that there is repigmentation in the hypopigmented areas after fractionated laser treatment. Can any of the panelists comment on this proposed mechanism of action? Dr. Zelickson: I would like to interject that I have treated many patients, and, as of now, this has not been my experience. Dr. Gregory: I have seen some improvement in dyschromia with the CO2 laser. If you observe the patchy brightness that is sometimes evident, I think you will see some improvement. I wonder if repigmentation is due to migration of melanocytes. Are we just uncovering, or perhaps activating, melanocytes, which are suppressed for one reason or another? I definitely think I am getting some improvement in the color of the hypopigmented areas with the CO2 laser.
Nonsurgical Skin Tightening Modalities
Dr. Zelickson: The disadvantage of the Fraxel device is that it requires a series of treatments but, for pigmentation, it works pretty well. I tell patients that they will most likely get a 40% to 60% improvement in skin pigmentation, with softening of facial lines, with a series of treatments with the Fraxel device. Currently, my treatment of choice is the CO2 Fraxel. I have just treated a series of patients with this device. Six or 8 weeks after treatment, I am seeing a significant improvement in lines, wrinkles, and pigmentation. One of those treatments would deliver the same results that I would expect to see with 3 or perhaps 4 of the standard Fraxel treatments. Currently, the device does not have approval from the Food and Drug Administration. Dr. Burns: Would you compare the downtime of the new fractional CO2 device from Reliant with the Fraxel SR1500 as well as standard ablative resurfacing? Dr. Zelickson: With the settings that I am using, I am seeing pinpoints that last for about a day, redness and
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Figure 3. This 57-year-old woman is concerned about dyschromia, lines around her eyes, crow’s-feet, and perioral lines.
swelling that resolve within a week, and sometimes a little redness after that. But it has been comparable to our more aggressive Fraxel treatment (the infrared 1550 Fraxel treatment). Dr. Dover: She would do beautifully. She has an unhappy look; she is relatively young and has very little sagging. She has a lot of epidermal photodamage, but she has good skin integrity, and use of any of the many different modalities will make her look much better. The key in the consultation is to find out exactly what bothers her. I think I would start simply, administering a series of 5 to 6 IPL rejuvenation treatments. Her pigmentation would improve more than 90%, her texture would improve about 20%, and she would look 10 years younger— like a new woman. If you want to improve texture and do something simple, she could be treated with a series of 5-amino levulin-
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ic acid (ALA) (Levulan; DUSA Pharmaceuticals, Wilmington, MA) followed 30 to 90 minutes later by IPL or pulsed dye laser. She will get 30% more improvement in texture by adding ALA. She should do beautifully with fractional treatments, and I probably would recommend a series of 6 treatments. She would do well with a superficial erbium peel. I would consider using botulinum toxin A (Botox; Allergan, Irvine, CA) to elevate the downward slant of the medial brow and then inject some Botox in the depressor anguli oris to help elevate her downturned mouth. Finally, I would use a little bit of Botox for the dynamic lines causing her vertical lip lines. I do not believe that she needs ablative resurfacing. Dr. Burns: What would you do for the upper lip lines if she did not want the downtime of standard CO2 or erbium resurfacing?
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Dr. Dover: All the problem areas we mentioned would get modest improvements with 6 fractional treatments with aggressive treatment around the mouth. We could get fairly good results with 3 or 4 superficial erbium laser treatments and good results with aggressive plasma skin rejuvenation, but not one of these options would be as good as CO2 laser resurfacing. Dr. Burns: Dr. Gregory, would you like to add something?
than working up slowly from 20% or 35%. Using this method, we get reproducibly good results in treating melasma. I rarely use IPL or fractional resurfacing for melasma. I like to start with the less expensive, less involved procedures. I will say, however, that on the occasions that I have gone on to use fractional resurfacing, I have had some modest improvement—no home runs, but encouraging results, and for the most part patients have been happy.
Dr. Gregory: The one thing I would add is to advise her that she has had poor skin care in the past, and I think good skin care is really the key to making treatment work over the long term. I would recommend tretinointype treatment and arrange a really good consultation with a skin care specialist that could follow her.
Dr. Burns: That is a great “non-laser” answer. In terms of Tri-Luma, is there a cheaper but comparable substitute? Tri-Luma is also my favorite, but some patients find it expensive. Can you combine a steroid cream and a hydroquinone mixture for convenience, or is it less effective?
Dr. Burns: The next patient is a 31-year-old woman with melasma of the right cheek (Figure 4). She had a superficial IPL treatment 3 months ago in another skin care clinic, but the lesion has recurred. Dr. Dover, if she approached you for treatment options, how would you address this difficult problem?
Dr. Dover: Before Tri-Luma was available, I sent a prescription to a pharmacy that is nationally recognized and highly skilled in compounding Kligman’s formula (tretinoin, steroid, and hydroquinone). Once Tri-Luma became available, I switched over. In most cases, whenever a standardized prescription cream is available I select it over a compounded one because you are assured of constancy in production and quality and bioavailability. Hydroquinone products are expensive, and unfortunately very few insurance companies cover the cost. But because melasma can be so devastating, for the most part patients are willing to pay for the prescription. To help patients, we start them off by giving them each a few free samples.
Dr. Dover: First, I would get a detailed history of exactly what she is doing in terms of skin care and sun protection and what medications and supplements she might be taking orally. Most significant is whether she is taking any form of oral estrogen. Patients must stop the oral contraceptive pill and any other hormone replacement or hormone therapy because if they do not, they will never get control of the condition. It is amazing how many patients I see with melasma who have seen dermatologists or plastic surgeons and still have not gotten any better. The second thing is sun protection. Patients need to be educated about the importance of sun protection, good sun screening against ultraviolet (UV) radiation, both B and A, and proper selection of broad-brimmed hats. My favorite prescription treatment today is Tri-Luma (Galderma Laboratories, Fort Worth, TX), a combination of retinoid, steroids, and 4% hydroquinone, which is applied once a day, usually at night. It is the most effective prescription item available in the United States for melasma. Depending on the patient’s desire to do more than just home therapy, we recommend aggressive glycolic peels, starting at either unbuffered 50% or 70% acid. These are usually performed by one of our nurses with me observing. We start at the high concentration rather
Nonsurgical Skin Tightening Modalities
Dr. Burns: Dr. Gregory, please tell us how you treat melasma. Dr. Gregory: I probably would be quicker to use the fractional laser than Dr. Dover, even combining that with the other modalities. I agree that you have to control the patient’s environment and physiology at the same time, doing whatever you can do to improve the pigmentation and educating them about prevention. Dr. Burns: Dr. Zelickson, is your approach similar? Dr. Zelickson: I have a couple of points to add. As Dr. Dover pointed out, it is very important to find out what these patients are taking by mouth. I have seen a number of women with melasma who have been taking herbal medications containing phytoestrogens found in red clover,
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Dr. Dover: That’s a great point. Unfortunately in Massachusetts it is illegal for physicians to dispense prescription pharmaceuticals. In states where it is allowed, a nice program is available in which you can pass on savings to the patients. Dr. Burns: The next patient is a 50-year-old woman who is adverse to surgery but wants to know if there is anything that can be done to improve the laxity in her jowls and in her submental skin (Figure 5). Dr. Gregory: Once again, I would recommend skin care, but I think Botox and fillers would be a very good alternative to surgery—although obviously it will not tighten her cheek skin. A nonablative tightening device might be the way to go with respect to resurfacing. The texture of her skin might be improved with Fraxel. I am not a big fan of radiofrequency or microwave machines. Dr. Burns: What if she came back and said “I am not interested in Botox and fillers, but what I really want to do is improve my jaw line and my neck.” As a plastic surgeon, would you offer her only surgery, or is there a nonsurgical alternative that you would entertain? Dr. Gregory: I believe that I would have to respond “surgery-or-nothing.” Figure 4. This 31-year-old woman has melasma of the right cheek. She had a superficial peel 3 months ago at another skin care clinic, but the lesion has now recurred.
and sometimes that can also make it difficult to eradicate their condition. Again, I have tried IPL like Dr. Dover, and one has to be very careful with postinflammatory hyperpigmentation, especially in a woman like this who appears to have a slightly darker skin type. I really have not had much success with IPL treatments or fractional resurfacing in these patients. A big concern is that it is very expensive and that the melasma can resurface. There have been no studies about longevity of response, and I think, certainly, you get some improvement, but the next summer patients go out and their pigmentation returns. One thing to mention about Tri-Luma is that in drug stores it is about $100 to $120 a tube, which really is not that much if it works, compared with the other treatment modalities we are talking about. I dispense this product through my office and pass the savings along to the patient, so it makes it more affordable.
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Dr. Burns: That is why you are on the panel. Dr. Zelickson, what are your thoughts? Dr. Zelickson: She actually would be a very good candidate for one of the nonablative tightening devices. Some people are reluctant to do these procedures because there is some variability. But as long as this patient is well counseled in the type of response to expect and the facts that the difference may be subtle, or there could be no improvement, I think she would make a great candidate for these devices in the submental and jaw line area. I would also treat the forehead and upper eyelids with the radiofrequency-based device to get some tightening there. That device works very well in combination with Botox to treat the nasolabial fold; you can get a little tightening and then add fillers. Dr. Burns: How would you respond if she asked, “What do you think my chances are of not seeing any improvement?” Also, what if she asked, “If I do see improvement, what do you think, in percentages, is the average tightening I might see?’’
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Dr. Dover: I actually think this patient is a very good candidate for the nonsurgical skin tightening approach. Even if she came in and asked directly about a face lift, I would say, “Look, you have an alternative,” because I have seen a lot of patients with similar skin who have done very nicely with skin tightening devices. Choices include Thermage’s ThermaCool (Hayward, CA), Syneron’s Emax (Richmond Hill, Ontario, Canada), Cutera’s Titan (Bayshore, CA), ALMA’s Accent (Caesarea, Israel), and Lumenis’ Aluma (Santa Clara, CA). These devices actually work. I believe there have been tremendous advances in the last 1 to 2 years on the basis of greater understanding of the correct protocol for treatment with these devices. For example, with the Thermage ThermaCool, lower energy and repeated passes produce more significant reproducible skin tightening. In the latest study of 5700 patients from 14 centers around the world, 94% of the physician-reviewed cases had improvement in skin tightening. A patient like this would actually get improvement of her jaw line, mid face, and upper neck, as Dr. Zelickson mentioned. I tell patients there is a 94% chance that they will see some pleasing improvement. It won’t be nearly as much as a face lift, but it will help. At the same time, I do try to screen out those patients who really should be undergoing more aggressive treatment to be satisfied.
Figure 5. This 50-year-old woman, who does not want surgery, is concerned about dyschromia, as well as skin laxity in her jowls and submental skin.
Dr. Zelickson: There will be a consensus paper coming out that Dr. Dover and I were involved with evaluating about 5700 patients treated with the radiofrequencybased device. The results of that study were quite impressive. But, what I tell my patients is that in about 10% to 15% of people, you will really not see improvement. However, we tend to see an improvement that would equal a movement of about 2 to 3 mm on the lower face. In talking with patients, I prefer to first have them look in the mirror while I try to show them, by moving the particular facial area about a centimeter, what an average surgical result might be. I then show them what I would expect to see as the result of the noninvasive tightening device, which is a movement of anywhere from 1 to 3 mm. Dr. Burns: Dr. Dover, any comments?
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Dr. Burns: The next patient is a 56-year-old man who is concerned about the redness in his face (Figure 6). I think his face should be blanched, starting out. Dr. Zelickson, what would you do? Do you consider this an easy or a tough case? Dr. Zelickson: I would take a closer look to make sure he does not have a lot of actinic damage because that would change my approach; it is difficult to know that from the photograph. If he does have actinic damage, I would treat discreet lesions with some liquid nitrogen. He is a very good candidate for the technique that Dr. Dover mentioned earlier, ALA photodynamic therapy, with either an IPL source or pulsed dye laser. I tend to use a small spot KTP laser that traces out the larger vessels and then use a large spot pulsed dye laser in a nonpurpuric fashion to treat the diffuse redness. With the newer pulsed dye systems, you can use the elongated pulse duration and spot sight to target the larger vessels. Alternatively, I could use an IPL device for the redness. He should do very well with these treatments. Dr. Burns: Do you have a preference for IPL versus the nonpurpuric pulsed dye lasers?
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tis, which responds to Nizoral shampoo (Johnson & Johnson, Somerville, NJ) applied to the face for 5 minutes daily. He has a red face with a lot of telangiectasia. There are many choices, all of which would yield significant improvement. I would use either a 595-nm pulsed dye laser, a pulsed dye laser with a concomitant 1064-nm Nd-YAG laser, such as the Cynergy, (Cynosure Inc., Westford, MA), with synchronized pulsing of pulsed dye, and then a long-pulse 1064-nm Nd-YAG laser, a long-pulsed green 532-nm laser (Gemini, Iridex, CA), or IPL. With the pulsed green laser, we have recently been using the 10-mm spot differently from what Dr. Zelickson described. We move the chilled laser tip slowly but surely across the face horizontally and then vertically. We just published results of a split-face study in Dermatologic Surgery, which compared the 532-nm pulsed laser with the pulsed dye laser for facial redness and vessels and, basically, the results were almost identical. So it really depends on the preference of the user; any one of those devices would give this man between 80% and 95% improvement after 3 to 4 treatments. He would get some swelling after each of those treatments, so he has to be warned. But he should not get purpura.
Figure 6. This 56-year-old man is concerned about the redness in his face.
Dr. Zelickson: If they are side by side, I will always choose the pulsed dye laser. The wavelength is more specific. Dr. Burns: Do you prefer that to the KTP system? Dr. Zelickson: Frequently, I use them together. Dr. Burns: Dr. Dover, would you approach this problem differently? Dr. Dover: This is the most frequently occurring problem I see in my practice; a red face with facial vessels is very common. This patient has some discreet actinic keratoses, especially in the area of his right lateral eyebrow. Liquid nitrogen would treat these beautifully. The scaling and redness between his brows is dermati-
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Dr. Burns: In your study, did you find that the Gemini 10-mm spot size produces a lot more swelling? How does that compare with the swelling that you get with the nonpurpuric pulsed dye treatment? Dr. Dover: In that study, each patient underwent very aggressive treatment. We first traced the vessels with the 5-mm spot and then painted half the face with the big 10-mm spot first horizontally then vertically. The pulsed green side was a little more painful than the pulsed dye laser side, and patients had a little more swelling on that side as well. There was also slightly more clearing on that side than the pulsed dye side. But both devices produced beautiful results, so I think it really comes down to a matter of user preference. Something we learned from that study is that applying ice for 10 minutes immediately after treatment and for 10 minutes of every hour for the rest of the day is as effective at reducing swelling as 30 mg of prednisone daily for 3 days. This has changed my practice. Dr. Zelickson: We never use prednisone anymore; we use ice very aggressively. I learned this from Arielle Kauver. At first, I didn’t believe it until we did the study.
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Dr. Burns: Have you used agents such as Benadryl (S.S. Pharmachem, Maharashtra, India) for swelling? Dr. Dover: If you use Benadryl, I would recommend that you pretreat the patient because it only works if you prevent the histamine cells from degranulating. Treatment with antihistamines administered after swelling has developed does not work at all. Dr. Zelickson: Benadryl makes patients sleepy, so I never prescribe it. Dr. Burns: Dr. Gregory, do you have anything to add? Dr. Gregory: I like the idea of the Gemini or some vascular lesion laser, but I also like the idea of using the ALA to start with. I think that it will clear up a lot of his actinic damage. Then I would work on the redness last, which can be easily treated with a laser. Dr. Burns: The last patient is a 59-year-old woman who is concerned about the redness in her lower neck (Figure 7). Dr. Dover, what would be your approach? Dr. Dover: This is a clear example of severe poikiloderma of Civatte, evident on this woman’s neck and chest. The sure way to identify it is that she has a V-shaped area under her chin that is completely spared where the sun never reached because of shadowing. By definition, in poikiloderma, there can be telangiectasia, hypopigmentation, and hyperpigmentation. This patient really has the telangiectatic version, which is the easiest to treat. The pigmentary component is much more challenging to improve. There are many different options. My favorite treatment by far is pulsed dye laser treatment using settings that induce slight purpura. I have learned that treating with longer pulse durations that do not induce purpura yields much less improvement per treatment. I use fluences just above the purpura threshold, using the biggest spot size available. In the case of the VBeam (Candela laser), I use the 10-mm spot 5.5 J/cm2 and a 1.5-ms pulse duration Occasionally, I will go up to 6 J/cm2. Patients usually get a little bit of purpura, which lasts from 3 to 5 days. The average result is 90% clearing in about 3 or 4 treatments (instead of 6 to 8 treatments with nonpurpuric settings), and this cost savings is significant for the patient. Other options are IPL and pulsed green 532-nm treatment. Regardless of which laser or light source you select, keep in mind that the
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Figure 7. This 59-year-old woman is concerned about the redness in her lower neck.
neck is more sensitive than the face, and overtreatment on the neck may lead to hypopigmentation or depigmentation and even textural change. Dr. Burns: Dr. Zelickson, what do you think? Dr. Zelickson: Dr. Dover points out that when you are too aggressive you get this reticulated response in which you clear the areas in the center of your pulses and the surrounding area does not clear. Frequently, I will not be as aggressive as Dr. Dover with a purpuric response. It sounds like his purpuric responses are still not excellent compared with what we used to do with the 0.5, which is much safer. I usually perform 2, 3, or sometimes 4 passes, and the downside of that is you can get a lot more swelling. But the upside is that you never get that reticulated response.
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Dr. Burns: Could you comment on the use of the IPL device for poikiloderma? Dr. Zelickson: I think you really have to be careful and knowledgeable of what you are doing, and we usually use it the way that Dr. Dover mentioned. This is mostly a telangiectatic form, but people commonly have a mixture of melanin pigmentation advancing along with it. I typically do 1 or 2 treatments with the IPL device to try to improve that (which usually works), and then frequently finish up with the pulsed dye system. Dr. Burns: Is there any role for the Fraxel device in treatment of poikiloderma with regard to the pigment? Has anyone tried that? Dr. Zelickson: I think it would help the pigment a bit— but not the vascular component. It is not the texture in these cases that bothers people, but rather the color, which you can see across the room. Dr. Burns: Dr. Dover, can you add anything concerning your approach? Dr. Dover: Tri-Luma actually works relatively well. It is probably the best of all of the bleaching agents for the pigmentary component. I sometimes start with that and then move on to the vascular component after lightening the pigments so that the pigment does not interfere with the vascular treatment. You have to be a bit cautious; the response is not as easy as with lentigines on the face or neck. The pigmentary component of poikiloderma can be resistant to treatment. Especially, if you are using an IPL, you have to be careful not to get striping or overdo treatment because the neck skin is so sensitive. If you know that it is potentially risky and proceed cautiously, I do not think things will go wrong. ■ Dr. Burns has received discounted equipment, consulting fees, research grants, and teaching honorariums from Candela, ConBio, Cynosure, Kushka Cosmetics, Laserscope, Lumenis, Palomar, Reliant, Sciton, Skin Medica, Thermage, Ulthera, and Zimmer. He also holds stock in Skin Medica and is a member of the Scientific Advisory Board for Juniper Medical and Ulthera. Dr. Zelickson has received research grants and equipment loans from Candela, Cutera, Dusa, Lumenis, Palomar, Reliant, Rhytec, and Thermage. Dr. Dover has received research grants and/or use of equipment from the following companies: Candela Laser, Cynosure, DUSA Pharmaceuticals, Iridex, Lumenis, OpusMed One, Palomar, Reliant, Rhytec, and Syneron. The other panelist has no financial interest in any of the products, devices, or drugs mentioned in this discussion.
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Bibliography Abraham MT, Mashkevich G. Monopolar radiofrequency skin tightening. Facial Plast Surg Clin North Am 2007;15:169–177. Bierring P, Christiansen K, Troilius A, Dierickx C. Facial photo rejuvenation using two different intense pulse light (IPL) wavelength bands. Lasers Surg Med 2004:34; 120–126. Chan HH, Manstein D, Yu CS, Shek S, Kono T, Wei WI. The prevalence and risk factors of post-inflammatory hyperpigmentation after fractional resurfacing in Asians. Lasers Surg Med 2007;39:381–385. Christiansen K, Bjerring P, Troilius A. 5-ALA for photodynamic photorejuvenation—optimization of treatment regime based on normal-skin fluorescence measurements. Lasers Surg Med 2007;39:302–310. Collawn SS. Fraxel skin resurfacing. Ann Plast Surg 2007;58:237–240. Dover JS, Series Editor. Lasers and Lights, Volumes 1 and 2. In: Goldberg D, ed. Procedures in Cosmetic Dermatology. Elsevier, 2006. 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 endpoint algorithm. Dermatol Surg 2007:in press. Goldman MP, Alster TS, Weiss R. A randomized trial to determine the influence of laser therapy, monopolar radiofrequency treatment, and intense pulse light therapy administered immediately after hyaluronic acid gel implantation. Dermatol Surg 2007;33:535–542. Iver S, Carranza D, Kolodney M, Macgregot D, Chips L, Soriano T. Evaluation of procollagen I deposition after intense pulsed light treatments at varying parameters in a porcine model. J Cosmet Laser Ther 2007;9:75–78. Kono T, Chan HH, Groff WF, Manstein D, Sakurai H. Takeuchi M, Yamaki T, Soejima K, Nozaki M. Prospective direct comparison study of fractional resurfacing using different fluences and densities for skin rejuvenation in Asians. Lasers Surg Med 2007;39:311–314. Rabman Z, Alan M, Dover JS. Fractional laser treatment for pigmentation and texture improvement. Skin Ther Lett. 2006;11:7–11. Rokhsar CK, Fitzpatrick RE. The treatment of melasma with fractional photothermolysis: a pilot study. Dermatol Surg 2005;31:1645–1650. Trelles MA, Mordon S, Calderhead RG. Facial rejuvenation and light: our personal experience. Lasers Med Sci 2007;22:93–99 Epub 2006 Nov 23. Wanner M, Tanzi EL, Alster TS. Fractional photothermolysis: treatment of facial and nonfacial cutaneous photodamage wiith a 1550-nm erbiumdoped fiber laser. Dermatol Surg 2007;33:23–28. Zachary CB. The effects of pulse energy variations on the dimensions of microscopic thermal treatment zones in nonablative fractional resurfacing. Lasers Surg Med. 2007;39:145–155. Reprint requests: A. Jay Burns, MD, 411 N. Washington, Suite 6000, Dallas, TX 75246. E-mail address: [email protected]. Copyright © 2007 by The American Society for Aesthetic Plastic Surgery, Inc. 1090-820X/$32.00 doi:10.1016.j.asj.2007.05.009
2007
Volume 27, Number 4
Panel Discussion
Nonsurgical Skin Tightening Modalities A. Jay Burns, MD; Jeffrey Dover, MD; Richard O. Gregory, MD; Brian Zelickson, MD Dr. Burns is Assistant Professor at the University of Texas Southwestern Medical Center, Dallas, TX. Dr. Dover is Associate Clinical Professor, Department of Dermatology, Yale University School of Medicine, New Haven, CT, and Adjunct Professor of Medicine (Dermatology) at Dartmouth College Medical School, Hanover, NH. Dr. Gregory is in private practice in Celebration, FL. Dr. Zelickson is Adjunct Associate Professor, Department of Dermatology, the University of Minnesota Medical School, Minneapolis, MN.
Dr. Burns: The first patient is a 67-year-old woman who has refused surgical correction (Figure 1). Her priority is to correct the looseness under her neck and jaw line, as well as to improve her general skin condition, which has been compromised by acne damage over her cheeks and forehead. She would also like the redness in her skin addressed. Dr. Dover, how would you approach treating this woman? How would you manage her expectations, and what could you realistically offer? Dr. Dover: I think what she really needs is a face lift, even though I know she is resistant. She has a heavy face with a lot of sagging and extreme neck A. Jay Burns, MD elasticity. Unless she has a surgical correction, she will never get dramatic improvement in her lower face. You could, however, use skin tightening devices and get some modest improvement. I have actually been pleasantly surprised that people with a significant degree of sagging do sometimes get Richard O. Gregory, MD noticeable tightening, but it is never dramatic. However, in patients such as this, I typically do not recommend nonsurgical skin tightening because the cost and time are not usually worth it. A far less significant issue, the redness, could be improved with a variety of devices, such as pulsed dye laser, a pulsed potassium-titanyl-phosphate (KTP) green light laser, or intense pulsed light (IPL). The latter two would also help with her pigmentation. But her big issue is sagging, which is pronounced.
Dr. Burns: Dr. Gregory, what would you suggest for this patient? Dr. Gregory: I agree with Dr. Dover’s recommendation for face lift. Although we understand what we can realistically achieve with nonsurgical treatment, I suspect that her expectations are too high. Her face has early basal cells or heavy actinic keratosis. I would consider using the CO2 laser because I believe I could get rid of all of that actinic damage with it. I have also been able to correct some pigmentation disorders and tighten skin a bit. I think she would be very likely to get some hypopigmentation, but her neck Jeffrey Dover, MD is very pale to start with, so I don’t think this would create a large discrepancy between her face and neck. Dr. Burns: Why do you think that she would most likely get some hypopigmentation?
Brian Zelickson, MD
Dr. Gregory: She is already very pale around her mouth and eyes. Her skin is generally very pale, with marked weathering.
Dr. Burns: That is a good point because a lot of people are confused about who gets hypopigmentation. Interestingly, type I and type II pale individuals are the prime candidates for development of hypopigmentation. Early on in the resurfacing experience, we worried about hypopigmentation in darker type IV and V skin, but this is fortunately very rare. Dr. Zelickson, do you have anything to add?
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Dr. Gregory: I think she would be a great candidate for some fractionated laser treatment because it would even out the skin color of the lentigos, brown pigmentation, and hypopigmentation, as well as improve the texture of her skin and acne scarring. Dr. Burns: Dr. Zelickson, do you agree with this approach? Dr. Zelickson: Yes, I think she is a perfect candidate. Dr. Burns: What could she expect out of the fractionated treatment? Dr. Zelickson: It will take a series of 4 to 6 treatments. I would try to lighten the skin surrounding the hypopigmented areas, rather than try to repigment those areas. Usually, I tell patients to expect 20% to 40% improvement in skin texture. After I complete the series of treatments, if a patient goes out and gets a lot of sun exposure, the sponging and the pigmentation can return, so I advise patients to be very vigilant with sun protection. Dr. Burns: Dr. Dover, would you like to add something?
Figure 1. This 67-year-old woman has refused surgical correction but is concerned with looseness under her neck and jowls, as well as the general actinic damage on her cheeks and forehead. She would also like the redness addressed.
Dr. Zelickson: We know that she is adamantly opposed to surgery but wants treatment. I think I might improve her quite a bit with fillers. I have been successful with patients like this in whom you can see the lateral jowls. So for this patient, assuming she did not have unrealistic expectations, I might recommend a nonablative tightening procedure combined with some type of filler. Dr. Burns: The next patient is a 47-year-old woman with a history of acne (Figure 2). I am not sure the photograph shows this well. Her acne scarring is moderate at best, not terrible, but she is left with some dyspigmentation of the left cheek and diffuse dyschromia. She is interested in improving her skin overall. Dr. Gregory, what would be your preferred treatment for this patient?
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Dr. Dover: She is actually a very good candidate for fractional laser treatment. I have been more and more impressed over the last 6 months with results in acne scarring from fractional resurfacing. Now that we have the experience from treating several hundred patients, I can report that, after 6 treatments, results in the treatment of acne scarring are as good as those achieved with CO2 laser resurfacing with far less risk. In fact, the results with fractional resurfacing may be slightly better. The benefit here would be for the hyperpigmentation and the texture. IPL is also an option if you wanted to improve color only and were far less bothered by texture. IPL may be appropriate for someone who wants to limit the cost or downtime of fractional resurfacing, which on average produces 3 days of redness and swelling. She would actually get better results in terms of pigmentary improvement with IPL than with the fractional laser resurfacing, but she would not get the same textural improvement. Dr. Burns: One of the mechanisms is that the improvement in hypopigmented areas would decrease the apparent difference between the varying areas of pigmentation. I have heard experts experienced with the Fraxel device (Reliant Technologies, Mountain View, CA) state strong-
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Dr. Dover: The only thing I would add is that this concept remains unproven. We are probably lightening pigment and making the patchy things blend better. Dr. Burns: The third patient is a 57-year-old woman who is concerned about dyschromia, lines around her eyes, and crow’s-feet (Figure 3). On the oblique view, you can also see dyschromia out towards her jaw. After discussing laser resurfacing with her, it became clear that she does not want the associated downtime. Dr. Zelickson, what would you suggest to her? Dr. Zelickson: It sounds like this patient is primarily interested in improving her pigmentation. I could certainly get good results with a series of IPL treatments and Botox along the crow’s-feet. That would yield a very good response. Other resurfacing techniques would also be appropriate. One could do a single pass of the CO2 or light erbium laser but, again, there is a little more downtime with that, and the lines around the crow’s-feet would still need to be treated with Botox. Another option is the Fraxel device. The fractionated devices would take a series of treatments, but you would expect modest improvement in the lines around the cheeks and, again, combine that with Botox. Dr. Burns: If you chose to use the Fraxel device, what would be your expectations for the patient? Figure 2. This 47-year-old woman with a history of acne is left with hypopigmentation of the left cheek and diffuse dyschromia.
ly that there is repigmentation in the hypopigmented areas after fractionated laser treatment. Can any of the panelists comment on this proposed mechanism of action? Dr. Zelickson: I would like to interject that I have treated many patients, and, as of now, this has not been my experience. Dr. Gregory: I have seen some improvement in dyschromia with the CO2 laser. If you observe the patchy brightness that is sometimes evident, I think you will see some improvement. I wonder if repigmentation is due to migration of melanocytes. Are we just uncovering, or perhaps activating, melanocytes, which are suppressed for one reason or another? I definitely think I am getting some improvement in the color of the hypopigmented areas with the CO2 laser.
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Dr. Zelickson: The disadvantage of the Fraxel device is that it requires a series of treatments but, for pigmentation, it works pretty well. I tell patients that they will most likely get a 40% to 60% improvement in skin pigmentation, with softening of facial lines, with a series of treatments with the Fraxel device. Currently, my treatment of choice is the CO2 Fraxel. I have just treated a series of patients with this device. Six or 8 weeks after treatment, I am seeing a significant improvement in lines, wrinkles, and pigmentation. One of those treatments would deliver the same results that I would expect to see with 3 or perhaps 4 of the standard Fraxel treatments. Currently, the device does not have approval from the Food and Drug Administration. Dr. Burns: Would you compare the downtime of the new fractional CO2 device from Reliant with the Fraxel SR1500 as well as standard ablative resurfacing? Dr. Zelickson: With the settings that I am using, I am seeing pinpoints that last for about a day, redness and
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Figure 3. This 57-year-old woman is concerned about dyschromia, lines around her eyes, crow’s-feet, and perioral lines.
swelling that resolve within a week, and sometimes a little redness after that. But it has been comparable to our more aggressive Fraxel treatment (the infrared 1550 Fraxel treatment). Dr. Dover: She would do beautifully. She has an unhappy look; she is relatively young and has very little sagging. She has a lot of epidermal photodamage, but she has good skin integrity, and use of any of the many different modalities will make her look much better. The key in the consultation is to find out exactly what bothers her. I think I would start simply, administering a series of 5 to 6 IPL rejuvenation treatments. Her pigmentation would improve more than 90%, her texture would improve about 20%, and she would look 10 years younger— like a new woman. If you want to improve texture and do something simple, she could be treated with a series of 5-amino levulin-
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ic acid (ALA) (Levulan; DUSA Pharmaceuticals, Wilmington, MA) followed 30 to 90 minutes later by IPL or pulsed dye laser. She will get 30% more improvement in texture by adding ALA. She should do beautifully with fractional treatments, and I probably would recommend a series of 6 treatments. She would do well with a superficial erbium peel. I would consider using botulinum toxin A (Botox; Allergan, Irvine, CA) to elevate the downward slant of the medial brow and then inject some Botox in the depressor anguli oris to help elevate her downturned mouth. Finally, I would use a little bit of Botox for the dynamic lines causing her vertical lip lines. I do not believe that she needs ablative resurfacing. Dr. Burns: What would you do for the upper lip lines if she did not want the downtime of standard CO2 or erbium resurfacing?
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Dr. Dover: All the problem areas we mentioned would get modest improvements with 6 fractional treatments with aggressive treatment around the mouth. We could get fairly good results with 3 or 4 superficial erbium laser treatments and good results with aggressive plasma skin rejuvenation, but not one of these options would be as good as CO2 laser resurfacing. Dr. Burns: Dr. Gregory, would you like to add something?
than working up slowly from 20% or 35%. Using this method, we get reproducibly good results in treating melasma. I rarely use IPL or fractional resurfacing for melasma. I like to start with the less expensive, less involved procedures. I will say, however, that on the occasions that I have gone on to use fractional resurfacing, I have had some modest improvement—no home runs, but encouraging results, and for the most part patients have been happy.
Dr. Gregory: The one thing I would add is to advise her that she has had poor skin care in the past, and I think good skin care is really the key to making treatment work over the long term. I would recommend tretinointype treatment and arrange a really good consultation with a skin care specialist that could follow her.
Dr. Burns: That is a great “non-laser” answer. In terms of Tri-Luma, is there a cheaper but comparable substitute? Tri-Luma is also my favorite, but some patients find it expensive. Can you combine a steroid cream and a hydroquinone mixture for convenience, or is it less effective?
Dr. Burns: The next patient is a 31-year-old woman with melasma of the right cheek (Figure 4). She had a superficial IPL treatment 3 months ago in another skin care clinic, but the lesion has recurred. Dr. Dover, if she approached you for treatment options, how would you address this difficult problem?
Dr. Dover: Before Tri-Luma was available, I sent a prescription to a pharmacy that is nationally recognized and highly skilled in compounding Kligman’s formula (tretinoin, steroid, and hydroquinone). Once Tri-Luma became available, I switched over. In most cases, whenever a standardized prescription cream is available I select it over a compounded one because you are assured of constancy in production and quality and bioavailability. Hydroquinone products are expensive, and unfortunately very few insurance companies cover the cost. But because melasma can be so devastating, for the most part patients are willing to pay for the prescription. To help patients, we start them off by giving them each a few free samples.
Dr. Dover: First, I would get a detailed history of exactly what she is doing in terms of skin care and sun protection and what medications and supplements she might be taking orally. Most significant is whether she is taking any form of oral estrogen. Patients must stop the oral contraceptive pill and any other hormone replacement or hormone therapy because if they do not, they will never get control of the condition. It is amazing how many patients I see with melasma who have seen dermatologists or plastic surgeons and still have not gotten any better. The second thing is sun protection. Patients need to be educated about the importance of sun protection, good sun screening against ultraviolet (UV) radiation, both B and A, and proper selection of broad-brimmed hats. My favorite prescription treatment today is Tri-Luma (Galderma Laboratories, Fort Worth, TX), a combination of retinoid, steroids, and 4% hydroquinone, which is applied once a day, usually at night. It is the most effective prescription item available in the United States for melasma. Depending on the patient’s desire to do more than just home therapy, we recommend aggressive glycolic peels, starting at either unbuffered 50% or 70% acid. These are usually performed by one of our nurses with me observing. We start at the high concentration rather
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Dr. Burns: Dr. Gregory, please tell us how you treat melasma. Dr. Gregory: I probably would be quicker to use the fractional laser than Dr. Dover, even combining that with the other modalities. I agree that you have to control the patient’s environment and physiology at the same time, doing whatever you can do to improve the pigmentation and educating them about prevention. Dr. Burns: Dr. Zelickson, is your approach similar? Dr. Zelickson: I have a couple of points to add. As Dr. Dover pointed out, it is very important to find out what these patients are taking by mouth. I have seen a number of women with melasma who have been taking herbal medications containing phytoestrogens found in red clover,
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Dr. Dover: That’s a great point. Unfortunately in Massachusetts it is illegal for physicians to dispense prescription pharmaceuticals. In states where it is allowed, a nice program is available in which you can pass on savings to the patients. Dr. Burns: The next patient is a 50-year-old woman who is adverse to surgery but wants to know if there is anything that can be done to improve the laxity in her jowls and in her submental skin (Figure 5). Dr. Gregory: Once again, I would recommend skin care, but I think Botox and fillers would be a very good alternative to surgery—although obviously it will not tighten her cheek skin. A nonablative tightening device might be the way to go with respect to resurfacing. The texture of her skin might be improved with Fraxel. I am not a big fan of radiofrequency or microwave machines. Dr. Burns: What if she came back and said “I am not interested in Botox and fillers, but what I really want to do is improve my jaw line and my neck.” As a plastic surgeon, would you offer her only surgery, or is there a nonsurgical alternative that you would entertain? Dr. Gregory: I believe that I would have to respond “surgery-or-nothing.” Figure 4. This 31-year-old woman has melasma of the right cheek. She had a superficial peel 3 months ago at another skin care clinic, but the lesion has now recurred.
and sometimes that can also make it difficult to eradicate their condition. Again, I have tried IPL like Dr. Dover, and one has to be very careful with postinflammatory hyperpigmentation, especially in a woman like this who appears to have a slightly darker skin type. I really have not had much success with IPL treatments or fractional resurfacing in these patients. A big concern is that it is very expensive and that the melasma can resurface. There have been no studies about longevity of response, and I think, certainly, you get some improvement, but the next summer patients go out and their pigmentation returns. One thing to mention about Tri-Luma is that in drug stores it is about $100 to $120 a tube, which really is not that much if it works, compared with the other treatment modalities we are talking about. I dispense this product through my office and pass the savings along to the patient, so it makes it more affordable.
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Dr. Burns: That is why you are on the panel. Dr. Zelickson, what are your thoughts? Dr. Zelickson: She actually would be a very good candidate for one of the nonablative tightening devices. Some people are reluctant to do these procedures because there is some variability. But as long as this patient is well counseled in the type of response to expect and the facts that the difference may be subtle, or there could be no improvement, I think she would make a great candidate for these devices in the submental and jaw line area. I would also treat the forehead and upper eyelids with the radiofrequency-based device to get some tightening there. That device works very well in combination with Botox to treat the nasolabial fold; you can get a little tightening and then add fillers. Dr. Burns: How would you respond if she asked, “What do you think my chances are of not seeing any improvement?” Also, what if she asked, “If I do see improvement, what do you think, in percentages, is the average tightening I might see?’’
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Dr. Dover: I actually think this patient is a very good candidate for the nonsurgical skin tightening approach. Even if she came in and asked directly about a face lift, I would say, “Look, you have an alternative,” because I have seen a lot of patients with similar skin who have done very nicely with skin tightening devices. Choices include Thermage’s ThermaCool (Hayward, CA), Syneron’s Emax (Richmond Hill, Ontario, Canada), Cutera’s Titan (Bayshore, CA), ALMA’s Accent (Caesarea, Israel), and Lumenis’ Aluma (Santa Clara, CA). These devices actually work. I believe there have been tremendous advances in the last 1 to 2 years on the basis of greater understanding of the correct protocol for treatment with these devices. For example, with the Thermage ThermaCool, lower energy and repeated passes produce more significant reproducible skin tightening. In the latest study of 5700 patients from 14 centers around the world, 94% of the physician-reviewed cases had improvement in skin tightening. A patient like this would actually get improvement of her jaw line, mid face, and upper neck, as Dr. Zelickson mentioned. I tell patients there is a 94% chance that they will see some pleasing improvement. It won’t be nearly as much as a face lift, but it will help. At the same time, I do try to screen out those patients who really should be undergoing more aggressive treatment to be satisfied.
Figure 5. This 50-year-old woman, who does not want surgery, is concerned about dyschromia, as well as skin laxity in her jowls and submental skin.
Dr. Zelickson: There will be a consensus paper coming out that Dr. Dover and I were involved with evaluating about 5700 patients treated with the radiofrequencybased device. The results of that study were quite impressive. But, what I tell my patients is that in about 10% to 15% of people, you will really not see improvement. However, we tend to see an improvement that would equal a movement of about 2 to 3 mm on the lower face. In talking with patients, I prefer to first have them look in the mirror while I try to show them, by moving the particular facial area about a centimeter, what an average surgical result might be. I then show them what I would expect to see as the result of the noninvasive tightening device, which is a movement of anywhere from 1 to 3 mm. Dr. Burns: Dr. Dover, any comments?
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Dr. Burns: The next patient is a 56-year-old man who is concerned about the redness in his face (Figure 6). I think his face should be blanched, starting out. Dr. Zelickson, what would you do? Do you consider this an easy or a tough case? Dr. Zelickson: I would take a closer look to make sure he does not have a lot of actinic damage because that would change my approach; it is difficult to know that from the photograph. If he does have actinic damage, I would treat discreet lesions with some liquid nitrogen. He is a very good candidate for the technique that Dr. Dover mentioned earlier, ALA photodynamic therapy, with either an IPL source or pulsed dye laser. I tend to use a small spot KTP laser that traces out the larger vessels and then use a large spot pulsed dye laser in a nonpurpuric fashion to treat the diffuse redness. With the newer pulsed dye systems, you can use the elongated pulse duration and spot sight to target the larger vessels. Alternatively, I could use an IPL device for the redness. He should do very well with these treatments. Dr. Burns: Do you have a preference for IPL versus the nonpurpuric pulsed dye lasers?
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tis, which responds to Nizoral shampoo (Johnson & Johnson, Somerville, NJ) applied to the face for 5 minutes daily. He has a red face with a lot of telangiectasia. There are many choices, all of which would yield significant improvement. I would use either a 595-nm pulsed dye laser, a pulsed dye laser with a concomitant 1064-nm Nd-YAG laser, such as the Cynergy, (Cynosure Inc., Westford, MA), with synchronized pulsing of pulsed dye, and then a long-pulse 1064-nm Nd-YAG laser, a long-pulsed green 532-nm laser (Gemini, Iridex, CA), or IPL. With the pulsed green laser, we have recently been using the 10-mm spot differently from what Dr. Zelickson described. We move the chilled laser tip slowly but surely across the face horizontally and then vertically. We just published results of a split-face study in Dermatologic Surgery, which compared the 532-nm pulsed laser with the pulsed dye laser for facial redness and vessels and, basically, the results were almost identical. So it really depends on the preference of the user; any one of those devices would give this man between 80% and 95% improvement after 3 to 4 treatments. He would get some swelling after each of those treatments, so he has to be warned. But he should not get purpura.
Figure 6. This 56-year-old man is concerned about the redness in his face.
Dr. Zelickson: If they are side by side, I will always choose the pulsed dye laser. The wavelength is more specific. Dr. Burns: Do you prefer that to the KTP system? Dr. Zelickson: Frequently, I use them together. Dr. Burns: Dr. Dover, would you approach this problem differently? Dr. Dover: This is the most frequently occurring problem I see in my practice; a red face with facial vessels is very common. This patient has some discreet actinic keratoses, especially in the area of his right lateral eyebrow. Liquid nitrogen would treat these beautifully. The scaling and redness between his brows is dermati-
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Dr. Burns: In your study, did you find that the Gemini 10-mm spot size produces a lot more swelling? How does that compare with the swelling that you get with the nonpurpuric pulsed dye treatment? Dr. Dover: In that study, each patient underwent very aggressive treatment. We first traced the vessels with the 5-mm spot and then painted half the face with the big 10-mm spot first horizontally then vertically. The pulsed green side was a little more painful than the pulsed dye laser side, and patients had a little more swelling on that side as well. There was also slightly more clearing on that side than the pulsed dye side. But both devices produced beautiful results, so I think it really comes down to a matter of user preference. Something we learned from that study is that applying ice for 10 minutes immediately after treatment and for 10 minutes of every hour for the rest of the day is as effective at reducing swelling as 30 mg of prednisone daily for 3 days. This has changed my practice. Dr. Zelickson: We never use prednisone anymore; we use ice very aggressively. I learned this from Arielle Kauver. At first, I didn’t believe it until we did the study.
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Dr. Burns: Have you used agents such as Benadryl (S.S. Pharmachem, Maharashtra, India) for swelling? Dr. Dover: If you use Benadryl, I would recommend that you pretreat the patient because it only works if you prevent the histamine cells from degranulating. Treatment with antihistamines administered after swelling has developed does not work at all. Dr. Zelickson: Benadryl makes patients sleepy, so I never prescribe it. Dr. Burns: Dr. Gregory, do you have anything to add? Dr. Gregory: I like the idea of the Gemini or some vascular lesion laser, but I also like the idea of using the ALA to start with. I think that it will clear up a lot of his actinic damage. Then I would work on the redness last, which can be easily treated with a laser. Dr. Burns: The last patient is a 59-year-old woman who is concerned about the redness in her lower neck (Figure 7). Dr. Dover, what would be your approach? Dr. Dover: This is a clear example of severe poikiloderma of Civatte, evident on this woman’s neck and chest. The sure way to identify it is that she has a V-shaped area under her chin that is completely spared where the sun never reached because of shadowing. By definition, in poikiloderma, there can be telangiectasia, hypopigmentation, and hyperpigmentation. This patient really has the telangiectatic version, which is the easiest to treat. The pigmentary component is much more challenging to improve. There are many different options. My favorite treatment by far is pulsed dye laser treatment using settings that induce slight purpura. I have learned that treating with longer pulse durations that do not induce purpura yields much less improvement per treatment. I use fluences just above the purpura threshold, using the biggest spot size available. In the case of the VBeam (Candela laser), I use the 10-mm spot 5.5 J/cm2 and a 1.5-ms pulse duration Occasionally, I will go up to 6 J/cm2. Patients usually get a little bit of purpura, which lasts from 3 to 5 days. The average result is 90% clearing in about 3 or 4 treatments (instead of 6 to 8 treatments with nonpurpuric settings), and this cost savings is significant for the patient. Other options are IPL and pulsed green 532-nm treatment. Regardless of which laser or light source you select, keep in mind that the
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Figure 7. This 59-year-old woman is concerned about the redness in her lower neck.
neck is more sensitive than the face, and overtreatment on the neck may lead to hypopigmentation or depigmentation and even textural change. Dr. Burns: Dr. Zelickson, what do you think? Dr. Zelickson: Dr. Dover points out that when you are too aggressive you get this reticulated response in which you clear the areas in the center of your pulses and the surrounding area does not clear. Frequently, I will not be as aggressive as Dr. Dover with a purpuric response. It sounds like his purpuric responses are still not excellent compared with what we used to do with the 0.5, which is much safer. I usually perform 2, 3, or sometimes 4 passes, and the downside of that is you can get a lot more swelling. But the upside is that you never get that reticulated response.
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Dr. Burns: Could you comment on the use of the IPL device for poikiloderma? Dr. Zelickson: I think you really have to be careful and knowledgeable of what you are doing, and we usually use it the way that Dr. Dover mentioned. This is mostly a telangiectatic form, but people commonly have a mixture of melanin pigmentation advancing along with it. I typically do 1 or 2 treatments with the IPL device to try to improve that (which usually works), and then frequently finish up with the pulsed dye system. Dr. Burns: Is there any role for the Fraxel device in treatment of poikiloderma with regard to the pigment? Has anyone tried that? Dr. Zelickson: I think it would help the pigment a bit— but not the vascular component. It is not the texture in these cases that bothers people, but rather the color, which you can see across the room. Dr. Burns: Dr. Dover, can you add anything concerning your approach? Dr. Dover: Tri-Luma actually works relatively well. It is probably the best of all of the bleaching agents for the pigmentary component. I sometimes start with that and then move on to the vascular component after lightening the pigments so that the pigment does not interfere with the vascular treatment. You have to be a bit cautious; the response is not as easy as with lentigines on the face or neck. The pigmentary component of poikiloderma can be resistant to treatment. Especially, if you are using an IPL, you have to be careful not to get striping or overdo treatment because the neck skin is so sensitive. If you know that it is potentially risky and proceed cautiously, I do not think things will go wrong. ■ Dr. Burns has received discounted equipment, consulting fees, research grants, and teaching honorariums from Candela, ConBio, Cynosure, Kushka Cosmetics, Laserscope, Lumenis, Palomar, Reliant, Sciton, Skin Medica, Thermage, Ulthera, and Zimmer. He also holds stock in Skin Medica and is a member of the Scientific Advisory Board for Juniper Medical and Ulthera. Dr. Zelickson has received research grants and equipment loans from Candela, Cutera, Dusa, Lumenis, Palomar, Reliant, Rhytec, and Thermage. Dr. Dover has received research grants and/or use of equipment from the following companies: Candela Laser, Cynosure, DUSA Pharmaceuticals, Iridex, Lumenis, OpusMed One, Palomar, Reliant, Rhytec, and Syneron. The other panelist has no financial interest in any of the products, devices, or drugs mentioned in this discussion.
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Bibliography Abraham MT, Mashkevich G. Monopolar radiofrequency skin tightening. Facial Plast Surg Clin North Am 2007;15:169–177. Bierring P, Christiansen K, Troilius A, Dierickx C. Facial photo rejuvenation using two different intense pulse light (IPL) wavelength bands. Lasers Surg Med 2004:34; 120–126. Chan HH, Manstein D, Yu CS, Shek S, Kono T, Wei WI. The prevalence and risk factors of post-inflammatory hyperpigmentation after fractional resurfacing in Asians. Lasers Surg Med 2007;39:381–385. Christiansen K, Bjerring P, Troilius A. 5-ALA for photodynamic photorejuvenation—optimization of treatment regime based on normal-skin fluorescence measurements. Lasers Surg Med 2007;39:302–310. Collawn SS. Fraxel skin resurfacing. Ann Plast Surg 2007;58:237–240. Dover JS, Series Editor. Lasers and Lights, Volumes 1 and 2. In: Goldberg D, ed. Procedures in Cosmetic Dermatology. Elsevier, 2006. 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 endpoint algorithm. Dermatol Surg 2007:in press. Goldman MP, Alster TS, Weiss R. A randomized trial to determine the influence of laser therapy, monopolar radiofrequency treatment, and intense pulse light therapy administered immediately after hyaluronic acid gel implantation. Dermatol Surg 2007;33:535–542. Iver S, Carranza D, Kolodney M, Macgregot D, Chips L, Soriano T. Evaluation of procollagen I deposition after intense pulsed light treatments at varying parameters in a porcine model. J Cosmet Laser Ther 2007;9:75–78. Kono T, Chan HH, Groff WF, Manstein D, Sakurai H. Takeuchi M, Yamaki T, Soejima K, Nozaki M. Prospective direct comparison study of fractional resurfacing using different fluences and densities for skin rejuvenation in Asians. Lasers Surg Med 2007;39:311–314. Rabman Z, Alan M, Dover JS. Fractional laser treatment for pigmentation and texture improvement. Skin Ther Lett. 2006;11:7–11. Rokhsar CK, Fitzpatrick RE. The treatment of melasma with fractional photothermolysis: a pilot study. Dermatol Surg 2005;31:1645–1650. Trelles MA, Mordon S, Calderhead RG. Facial rejuvenation and light: our personal experience. Lasers Med Sci 2007;22:93–99 Epub 2006 Nov 23. Wanner M, Tanzi EL, Alster TS. Fractional photothermolysis: treatment of facial and nonfacial cutaneous photodamage wiith a 1550-nm erbiumdoped fiber laser. Dermatol Surg 2007;33:23–28. Zachary CB. The effects of pulse energy variations on the dimensions of microscopic thermal treatment zones in nonablative fractional resurfacing. Lasers Surg Med. 2007;39:145–155. Reprint requests: A. Jay Burns, MD, 411 N. Washington, Suite 6000, Dallas, TX 75246. E-mail address: [email protected]. Copyright © 2007 by The American Society for Aesthetic Plastic Surgery, Inc. 1090-820X/$32.00 doi:10.1016.j.asj.2007.05.009
2007
Volume 27, Number 4