Aging and sun damage of the skin results in skin laxity, rhytides, texture irregularities, dyspigmentation, and vascular changes. Many different laser devices are frequently used to correct these changes from age and photodamage. This article describes the author’s experience in combining laser technologies (different wavelengths and applications) in one treatment session to achieve better outcomes with fewer visits for the patient.
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Different lasers can be combined safely and effectively in same treatment session.
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Choice of lasers depends on skin type of patient, degree of sun damage, and goals of treatment.
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Frequently used combinations include the combination of vascular lasers with lasers to target pigment and the combination of one or both of these with fractional nonablative lasers.
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Laser treatments can be combined with fractional ablative lasers but with greater caution due to the amount of heat delivered to skin during fractional ablation.
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Combinations of lasers can achieve better outcomes in fewer sessions and lead to greater patient satisfaction.
Video of Surgical Technique for fractional ablative laser treatment in combination with punch excisions and the CROSS technique and suturing of the surgical defects at http://www.facialplastic.theclinics.com/ .
Cosmetic surgeons have an ever-expanding variety of devices and products to improve the appearance of aging skin and improve the changes from facial aging. Several neuromuscular relaxers are now used to treat and prevent facial lines that occur from the action of muscle movement. A variety of dermal fillers are used to fill lines and restore facial volume. Radiofrequency (RF) and ultrasound energy devices are used to tighten skin and stimulate collagen production in the skin.
Numerous light-based and energy-based devices can target the visible changes of aging and sun damage on the skin. There are ablative and nonablative lasers in the infrared spectrum that improve the appearance of wrinkles, skin texture, and acne scars. Lasers devices that have wavelengths in the visible light spectrum can specifically target melanin or hemoglobin to treat the dyspigmentation and vascular changes that occur with photoaging. Broad-spectrum intense pulsed light (IPL) devices have the ability to target pigment, erythema, and telangiectasia via a variety of wavelengths.
Several devices have combination therapies built in. RF energy has been combined with IPL and diode laser in several devices. The goal of the combination of technology is to achieve skin tightening and improvement in the visible changes of sun damage in the skin or enhancement of the improvement seen with the light-based device alone. Sadick and colleagues reported significant overall skin improvement (75.3%) and significant patient satisfaction (92%) using a novel device called electro-optical synergy that combines RF and IPL energy in a single pulse. In 2006, Alexiades-Armenakas evaluated the sequential combination use of two devices that combined bipolar RF with light-based energy. One device combined RF with diode laser and the other device combined RF with IPL. Blinded physician evaluation of improvement per category (rhytides, laxity, elastosis, dyschromia, erythema-telangiectasia, keratoses, and texture) after each treatment was mild (average improvement of 10.9% per treatment), but overall patient satisfaction was significantly higher (71.4%). Patient satisfaction was attributed to the use of a combination device that combined three nonablative technologies.
Studies evaluating combination laser treatment
Several studies have evaluated the combinations of different lasers in the same session for the cosmetic enhancement of facial skin. Berlin and colleagues reported successful combination of very light erbium followed sequentially by IPL. Twelve of 15 patients finished the study and reported mild erythema lasting up to 1 week and mild scaling for 3 to 4 days after the treatment. Overall satisfaction at 3-month follow-up was 63%. A study by Lee compared the efficacy of the 532-nm, ms potassium titanyl phosphate alone and the 1064-nm, ms neodymium (Nd:YAG) alone, as well as in combination, for the treatment of skin changes from photoaging. The combination of the two wavelengths gave slightly greater results than either alone. A similar study by Tan and colleagues was a split-face study that showed slightly greater improvement in the side that had received combination treatment of 532 nm and 1064 nm wavelengths. Studies by Goldman and Manuskiatti and by Goldman and colleagues have shown benefit in sequential use of ablative erbium immediately after ablative CO 2 laser in resurfacing to improve healing times and outcomes.
Combination of q-switched lasers (532 followed by 1064 nm) was shown to be significantly more effective in the treatment of Hori nevus than 1064 nm alone. A higher incidence of postinflammatory hyperpigmentation was seen on the combination laser side but all resolved in 2 months. Trelles and colleagues reported better results in leg vein treatment (blue veins and veins >1 mm responded best) using a laser that combined a pulsed dye and Nd:YAG laser sequentially in the same pulse. The sequential pulsed dye 1064 nm Nd:YAG laser has also been reported to be an effective and safe treatment for venous malformation.
Nonfacial laser applications
In nonfacial rejuvenation applications, lasers have been combined to remove tattoos as well as unwanted hair. Recently, Weiss and Geronemus reported more efficient tattoo removal with sequential q-switched ruby laser followed by ablative fractional resurfacing in the same session. Not all studies have shown benefit in combining wavelengths in the same session. A private group in Tehran, Iran, reported a study of laser hair removal on the legs using either 755 nm alexandrite, 1064 nm Nd:YAG, or a combination of both lasers. There was greater pain and increased side effects in the area treated with the combination of the two wavelengths.
Nonfacial laser applications
In nonfacial rejuvenation applications, lasers have been combined to remove tattoos as well as unwanted hair. Recently, Weiss and Geronemus reported more efficient tattoo removal with sequential q-switched ruby laser followed by ablative fractional resurfacing in the same session. Not all studies have shown benefit in combining wavelengths in the same session. A private group in Tehran, Iran, reported a study of laser hair removal on the legs using either 755 nm alexandrite, 1064 nm Nd:YAG, or a combination of both lasers. There was greater pain and increased side effects in the area treated with the combination of the two wavelengths.
Clinical experience: nonablative lasers
Even in young patients with early changes of sun damage, there are often several different aspects of photoaging present: lentigenes, erythema, telangiectasia, and wrinkles or skin texture changes. I have found that treatment outcomes and patient satisfaction are increased when these different aspects of photodamage are targeted in the same session.
Redness and Telangiectasia
The long-pulsed dye laser is an excellent choice for reducing redness and telangiectasias. Larger telangiectasia are more effectively treated with a 1064 nm Nd:YAG laser. The longer wavelength can penetrate more deeply and better reach the larger, deeper vessels. In addition, longer pulse widths can be matched to larger vessel size. In the treatment of redness and capillaries, such as is often seen in rosacea as well as sun damage, I often combine both the 595 nm pulsed dye laser (Vbeam Perfecta, Candela Corporation, Wayland, MA, USA) and the long-pulsed 1064 nm Nd:YAG laser (GentleYag, Candela Corporation, Wayland, MA, USA).
The 1064 nm wavelength is first used to treat the more visible and larger telangiectasias. Next, immediately after treatment with the Nd:YAG, the pulsed dye laser is used to treat the finer vessels and diffuse erythema. This combination is so frequently used together that the lasers are kept in the same room.
Dyspigmentation
When there is dyspigmentation in addition to redness and telangiectasia, I often choose an IPL device. The IPL has a spectrum of wavelengths with an upper and lower cutoff point. These varied wavelengths can treat erythema as well as pigment. Because the energy is spread over a range of wavelengths, no single wavelength is particularly focused or powerful. Thus, the IPL is best used for mild changes, maintenance, or for those who desire a treatment with minimal downtime.
With more significant changes of either a vascular or a pigmented nature, better results may be achieved using lasers whose wavelengths more specifically target the defect. Additionally, when there is more severe sun damage with a significant amount of erythema and numerous lentigenes, the IPL frequently leaves well-demarcated areas of clearance in the rectangular delivery crystal. Although this can also occur with the use of the pulsed dye laser, it is much easier and safer to overlap the smaller, round spot size of the pulsed dye laser and the areas of clearance are more subtle and blended.
I frequently combine a vascular laser treatment (595 nm pulsed dye, 1064 nm Nd:YAG, or both) with a laser treatment specifically targeting the pigmented areas of concern. Specific situations include:
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If the pigmented lesions are freckles or lentigenes, a long-pulsed 755 nm alexandrite laser (Candela Gentlase, Candela Corporation, Wayland, MA, USA) is often used at a low fluence with no epidermal cooling (ie, dynamic cooling turned off).
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Typically a spot size of 12 mm and energy setting of 16–30 J/cm 2 is used, depending on patient skin type and darkness of the lesion.
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Lower fluence is used for darker skin Types III and IV
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Higher fluence can be used in fairer skin Types I and II with lighter hair and eye color.
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The long-pulsed alexandrite is not used on tanned skin or any skin darker than Type IV.
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The lighter the lesion, the more energy is required to have an effect on the target.
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For darker lesions, lower energy is needed to achieve a clinical effect and to minimize side effects.
This combination of lasers can also be effective for the treatment of sun damage on the chest, which frequently has significant erythema as well as pigmentation.
Large Areas of Pigment
For larger areas of pigment or large patches of pigment, such as seen in melasma, a nonablative fractional laser (1550 nm or 1927 nm) is used either alone or in combination with low-energy, long-pulsed alexandrite laser before the fractional laser. If there is any erythema or telangiectasias, it is treated with one or both of the vascular lasers before treatment with the nonablative fractional laser. There is a nominal charge for the additional laser treatments and patient satisfaction with the treatment is greatly increased because several different aspects of skin concerns are taken care of in one session. If all lasers are used, the treatment series order is: (1) vascular lasers, (2) long-pulse alexandrite, (3) fractional nonablative laser.
Photodamage
When there are more significant texture changes or rhytides from sun damage, my preference is to use a nonablative fractional device to achieve improvement. To achieve the most consistent and quick results with pigment when a patient is having a series of fractional nonablative treatments, the long-pulse alexandrite laser is often used, as described above, before the fractional laser on the same day.
Similarly, erythema and telangiectasias are pretreated with a vascular laser before the fractional treatment. Fractional nonablative lasers do effectively treat pigment but the response is enhanced with pretreatment with the alexandrite laser. Patients note immediate improvement with reduction of pigmented lesions, whereas the collagen remodeling takes several months to occur. Figs. 1–3 show patients treated with combination of nonablative lasers.
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