The application of infrared broadband light is the more recent addition of nonsurgical laser and light-based treatment for skin laxity and rhytids. Infrared broadband light, when used with the mobile technique, offers a painless, safe, nonsurgical alternative treatment option for treatment of skin laxity on the face and neck. Multiple clinical studies have demonstrated improvements in skin laxity correlated histologically with neocollagenesis and neoelastogenesis over a 6–12 month period. The consistency of clinical improvement in skin laxity supports the use of this approach for moderate skin laxity.
The application of infrared broadband light to the treatment of facial and neck skin laxity has contributed greatly to the laser, light-based, and energy-based technologies designed to deliver volumetric heating in the treatment of skin laxity. When applied and used properly, infrared broadband (1100 to 1800 nm) light yields consistent and reproducible improvements in skin laxity to the face and neck without recovery time, side effects, or significant complications.
Patient Consult
Early users are advised to start with careful patient selection. Patients with a baseline skin laxity of 2 to 3 on the 4-point quantitative laxity grading scale ( Table 1 ) are optimal candidates; patients with severe skin laxity of grade 4 should expect the necessity for more treatment sessions to obtain appreciable improvement. Patients older than 65 are less responsive because of age-related changes in connective tissue.
The consultation should entail the presentation of all treatment options, including the surgical facelift.
The rare risk of a burn and the ensuing rare potential for a scar should be discussed during the informed consent process. The device is approved by the Food and Drug Administration for deep dermal heating and the application for the treatment of rhytids and skin laxity are off-label.
It is imperative to take baseline digital photographs of all patients so as to track progress with each treatment. Patients should be advised that results will start to become evident 2 weeks following the first treatment and that 2 to 3 monthly treatment sessions are required for significant improvement for patients with baseline laxity grade of 2 to 3 and 5 to 6 treatments for baseline laxity grade 3.5 to 4.0.
Technique
Early users are advised to start with the mobile technique at conservative fluences of 44 to 46 J/cm 2 for the face and 42 to 44 J/cm 2 to the neck. Apply ample aqueous gel to the area to be treated. A series of 8 passes to each row along the face and neck should be administered, so that the total pulse count for the face and neck should number 800.
As one develops experience with the device, the fluence may be titrated up to as high as 50 J/cm 2 for the face and 47 J/cm 2 for the neck as tolerated by the patient. Special attention should be given to treating the mandibular or bony prominences so that the sapphire tip is in full contact with the gel and parallel with the skin surface. Continual rapid movement of the tip is necessary to prevent discomfort and virtually eliminate the risk of burns. Total pulse counts for a face and neck treatment vary, depending on the size of the face and neck, and typically run between 200 and 400 pulses.
Technique
Early users are advised to start with the mobile technique at conservative fluences of 44 to 46 J/cm 2 for the face and 42 to 44 J/cm 2 to the neck. Apply ample aqueous gel to the area to be treated. A series of 8 passes to each row along the face and neck should be administered, so that the total pulse count for the face and neck should number 800.
As one develops experience with the device, the fluence may be titrated up to as high as 50 J/cm 2 for the face and 47 J/cm 2 for the neck as tolerated by the patient. Special attention should be given to treating the mandibular or bony prominences so that the sapphire tip is in full contact with the gel and parallel with the skin surface. Continual rapid movement of the tip is necessary to prevent discomfort and virtually eliminate the risk of burns. Total pulse counts for a face and neck treatment vary, depending on the size of the face and neck, and typically run between 200 and 400 pulses.
Maintenance and Follow-up
Patients should be followed at a 1-month interval and repeat photography is advised at each visit. Patients should be told at the outset that the final clinical outcome will take up to 6 to 12 months to manifest following the final treatment, paralleling the time course of neocollagenesis and neoelastogenesis. Maintenance treatments are generally advised once every 6 months.
Clinical examination and patient history
The classification of neck laxity and photoaging into quantitative grades has been previously published and evaluated for clinical trial use by the author (see Table 1 ). Patients with a baseline laxity grade of 2.0 to 3.0 are ideal candidates; patients with a baseline grade of 3.5 to 4.0 are advised that more treatment sessions are necessary to attain appreciable improvement. Patients older than 65 are less likely to respond to skin surface–applied nonablative treatments, and therefore are strongly discouraged from this approach. Patients with a history of thyroid or parathyroid disease or neoplasia are contraindicated. Baseline and follow-up photography amphas, three-quarter view, and from both side views are necessary. As aforementioned, patients should be offered all the treatment options for treating their skin laxity, including but not limited to injectables, laser and light-based treatments, surgical facelifting and no treatment. The rare but real risk of a thermal burn and scar should be discussed during informed consent, in addition to the usual and customary risks and complications of any medical procedure. Premedication and anesthesia are not necessary.
| Categories of Skin Aging and Photodamage | ||||||||
|---|---|---|---|---|---|---|---|---|
| Grading Scale | Descriptive Parameter | Rhytides | Laxity | Elastosis | Dyschromia | Erythema-Telangiectasia (E-T) | Keratoses | Texture |
| 0 | None | None | None | None | None | None | None | None |
| 1 | Mild | Wrinkles in motion, few, superficial | Localized to nasolabial (nl) folds | Early, minimal yellow hue | Few (1–3) discrete small (<5 mm) lentigines | Pink E or few T, localized to single site | Few | Subtle irregularity |
| 1.5 | Mild | Wrinkles in motion, multiple, superficial | Localized, nl and early melolabial (ml) folds | Yellow hue or early, localized periorbital (po) elastotic beads (eb) | Several (3–6), discrete small lentigines | Pink E or several T localized 2 sites | Several | Mild irregularity in few areas |
| 2 | Moderate | Wrinkles at rest, few, localized, superficial | Localized, nl/ml folds, early jowels, early submental/submandibular (sm) | Yellow hue, localized po eb | Multiple (7–10), small lentigines | Red E or multiple T localized to 2 sites | Multiple, small | Rough in few, localized sites |
| 2.5 | Moderate | Wrinkles at rest, multiple, localized, superficial | Localized, prominent nl/ml folds, jowels and sm | Yellow hue, po and malar eb | Multiple, small and few large lentigines | Red E or multiple T, localized to 3 sites | Multiple, large | Rough in several, localized areas |
| 3 | Advanced | Wrinkles at rest, multiple, forehead, periorbital and perioral sites, superficial | Prominent nl/ml folds, jowels and sm, early neck strands | Yellow hue, eb involving po, malar and other sites | Many (10–20) small and large lentigines | Violaceous E or many T, multiple sites | Many | Rough in multiple, localized sites |
| 3.5 | Advanced | Wrinkles at rest, multiple, generalized, superficial; few, deep | Deep nl/ml folds, prominent jowels and sm, prominent neck strands | Deep yellow hue, extensive eb with little uninvolved skin | Numerous (>20) or multiple large with little uninvolved skin | Violaceous E, numerous T little uninvolved skin | Little uninvolved skin | Mostly rough, little uninvolved skin |
| 4 | Severe | Wrinkles throughout, numerous, extensively distributed, deep | Marked nl/ml folds, jowels and sm, neck redundancy and strands | Deep yellow hue, eb throughout, comedones | Numerous, extensive, no uninvolved skin | Deep, violaceous E, numerous T throughout | No uninvolved skin | Rough throughout |
Method of device or treatment application
Protocol
Patient preparation
No topical anesthetic is needed for the procedure. A thin, 1-mm layer of aqueous ultrasound gel is applied. The typical treatment areas include the lower face and neck, excluding the thyroid region (see Fig. 1 ) .
Treatment intervals
Patients with baseline laxity grades 2 to 3 should receive 2 to 3 treatments with infrared broadband (1100 to 1800 nm) light at 2-week to 4-week intervals.
Mobile pulse application
Each light pulse is administered in a mobile continuous fashion within a localized area measuring approximately 1 handpiece width laterally and vertically. The handpiece is moved with the initiation of each pulse, making oval/circular movements extending approximately 1 width laterally to the handpiece tip and 1 length of the handpiece tip vertically. The pulses are delivered in succession along each row of facial or neck skin. A series of 4 to 5 pulses are administered across small grid areas, followed by 6 to 8 passes to each grid area, totaling approximately 200 to 400 pulses per treatment. The pulses should be administered in a linear fashion along the jawline, along the upper neck, and in the submental area. The precise segments or grid areas include the lower cheek, mid-to-upper cheek, mandible, upper lateral neck, and submandibular and submental areas. The passes are administered in succession to each linear area before commencing in a new area. A minimum of 4, but preferably 7 to 8 passes along each segment each covering an area of approximately 1.5 cm 2 should be administered. See Video 1 , Titan Mobile, online for demonstration of procedure.
Dose/fluence
Precooling, parallel cooling, and postcooling of the epidermis is applied through continuous contact with a sapphire tip. Each mobile pulse is delivered at a fluence of 46 J/cm 2 to the face, 45 J/cm 2 to the mandible, and 44 J/cm 2 to the neck. The fluence is commenced at 46 J/cm 2 for the mobile protocol to the face; 45 J/cm 2 to the mandible; and 44 J/cm 2 to the neck. If the patient senses momentary transient discomfort, the fluence should be titrated down by 1 J/cm 2 for a final target range on the face of 44 to 50 J/cm 2 ; for the neck, 42 to 47 J/cm 2 mobile. For superior periorbital regions, the mobile technique is initiated at fluences ranging from 20 to 24 J/cm 2 . One to 2 adjacent pulses may be administered to each brow extending to the lateral periorbital region. A total of 4 to 5 passes should be delivered and are comfortably tolerated by the patient. Good contact with ample aqueous gel is crucial.
Clinical evaluations
Clinical results should be evaluated using the comprehensive 4-point grading scale from photographs at baseline, and 1-month, 3-month, and 6-month follow-up visits after the final treatment.
Pain evaluations
Pain should be evaluated while administering each pulse and the fluence titrated up or down to the point of tolerability by the patient to maximize total energy delivery and safety.
Postoperative Care
Postoperative erythema resolves within minutes to hours and no postoperative care is needed.
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