Fractional Erbium Laser for Vaginal Rejuvenation

Evgenii Leshunov

Key Points

• Er:YAG 2940 nm is one of the most popular systems for laser vaginal rejuvenation in the world.

• This technology has been used to treat the syndrome of vaginal relaxation, stress urinary incontinence, and vaginal atrophy.

• Fractional vaginal rejuvenation is a simple outpatient procedure that requires no anesthesia.

• The rehabilitation period after vaginal rejuvenation with the use of an erbium laser is 72 hours.

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Dr. Leshunov consults and presents at congresses for Asclepion Laser Technologies.

Collagen is an important component of pelvic floor supportive structures—it makes up more than 80% of the protein content of the endopelvic fascia. Collagen provides tensile strength and integrity, and elastin is responsible for the elasticity and resilience of the connective tissue of the pelvic floor. The extracellular matrix of the vaginal wall consists of collagen type I, III, and V. The ratio of collagen type I/type III determines the mechanical properties of the vaginal wall. A change in the ratio toward collagen type III, which is most frequently observed in vaginal prolapse and stress incontinence, can significantly reduce the elasticity of the vaginal wall.

Fractional Er:YAG systems with a dedicated gynecological delivery system recently became commercially available.

Er:YAG systems offer a nonsurgical approach for vaginal tightening. Erbium laser technology is used for treating vaginal laxity, stress urinary incontinence, pelvic organ prolapsed, and vaginal atrophy. The first trials for erbium tightening of the vaginal canal began in 2008 and 2009.1

From 2010 to 2014 several clinical studies involving all four indications were conducted to prove the efficacy and safety of this novel technology. The infrared erbium (Er:YAG) laser has an emission wavelength of 2.94 µ and operates in pulse mode. The main mechanism of action of the laser technology is selective stimulation of the submucosal (lamina propria) collagen synthesis and thermal stimulation of mucosal tissue. The instantaneous reaction of contraction in the collagen fibers and acceleration of neocollagenesis lead to the contraction of tissues and an increase in their elasticity.

The choice of the Er:YAG with its 2940 nm wavelength for this gynecological probe-based system was predicated on the absorption peak of water at that wavelength. Human tissues are a good target for this wavelength because of their very high percentage of water, especially in the vaginal area where mucous membranes are present and in the lamina propria (submucosal area). Because of the extremely high absorption in water, the incident photon energy is almost totally quenched in the first micrometers of tissue, producing at appropriate parameters a very controlled column of thermal stimulation with an extremely narrow band of secondary coagulation, known as residual thermal damage.2

Collagen type V is an important component of basement membranes. Changes in the condition of this collagen are very rare. Elastin helps to provide support to the pelvic floor. With age, decreased elastin in the extracellular matrix causes a loss of submucosal supporting function of the vaginal wall.³

Pelvic tissue from women with stress urinary incontinence and pelvic organ prolapse shows a genetic predisposition to abnormal extracellular matrix remodeling, which is modulated by reproductive hormones, trauma, mechanical stress load, and aging. This progressive remodeling contributes to stress urinary incontinence and pelvic organ prolapse by altering normal tissue architecture and mechanical properties. Laser-mediated mechanical and heat pulsing of the endopelvic fascia and pelvic floor tissue could be an effective nonsurgical method for treating female urinary incontinence and other disorders resulting from diminished pelvic floor support.

Collagen that undergoes appropriate mechanical (ablative) and/or thermal microdamage is regenerated, resulting in more elasticity, tightening in the sudden contraction of its fibers, and contraction and shrinking of the irradiated bulk tissue.⁴ The result is a better response by muscular tissue in the pelvic floor.

Dr. Rodolfo Milani conducted a pilot study at the University of Milano-Bicocca, San Gerardo Hospital in Monza, Italy, to evaluate the safety and efficacy of a novel treatment protocol for vaginal rejuvenation using Er:YAG. Forty-seven patients received treatment for vaginal atrophy between December 2015 and April 2016. The average patient age was 55 years. Every 2 weeks, patients underwent a vaginal atrophy assessment (speculum examination and vaginal pH) and completed questionnaires on atrophy symptoms and quality of life (Utian Quality of Life [UQOL] Scale).⁵