Introduction to Alternative Techniques of Oculofacial Rejuvenation

Stephen Bosniak

A variety of noninvasive techniques now exist for rejuvenating facial skin. We can separate them into three categories: (1) improving skin texture and pigmentation, (2) rhytid ablation, and (3) skin tightening.

Improving Skin Texture and Pigmentation

Intense pulsed light (IPL) is the workhorse in this category (see Chapter 2) for diminishing dyspigmentation, telangiectasis, and background erythema. Although improvement in skin texture is not its primary function, these changes do occur.

Recently, light-emitting diodes (LEDs) have added further subjective improvement, enhancing the results of IPL and providing a molecular basis for clinical benefits. LED photomodulation uses coded pulses of low energy, nonlaser, nonthermal, light energy to stimulate mitochondrial activity, increase collagen and fibroblast production, and decrease collagenase (metalloproteinase). The currently recommended regimen is 50 seconds weekly for 8 weeks.^1–3

Nonablative neodynium:yttrium-aluminum-garnet (Nd:YAG) lasers create a perivascular inflammatory response and secondary neocollagenogenesis while protecting the skin surface with a cryogen spray. Our experience with 1320 nm (Cool Touch II) (Cutera, Brisbane, California) has been generally positive with properly selected patients of all skin types, particularly for patients with mild rhytidosis and irregular facial suface contours resulting from acne scarring.^4,5 They have enjoyed substantial improvement after 4 to 6 monthly treatments. A dynamic tetrafluoroethane spray is synchronized to be applied to the skin for 30 msec with a delay of 40 msec before each laser pulse to the skin (precooling), while monitoring the skin surface temperature with a thermal sensor in the laser handpiece.⁶ The desired endpoint is 41 to 45°C. In a similar fashion, the depth of the treatment can be varied, applying the cryogen spray immediately following each laser pulse (postcooling). We employ one precooling and two postcooling applications in our treatment sessions. Postprocedure erythema is typically gone within 30 minutes, or less if a Natragel mask (Gel Concept, Whippany, New Jersey) is applied. Improvement in skin texture is not usually evident for 4 to 6 months after the initiation of treatment. Although recovery time is minimal, we feel that the drawbacks are the discomfort during the procedure (even with topical anesthetic), and the subtlety of the improvement.

Although we have had no experience with the 1540 nm Er:Glass laser (Aramis, Quantel Medical, Clermont-Ferrand, France), it may also be another potential nonablative tool for improving surface irregularities following acne and actinic changes.^7,8

Rhytid Ablation

The selection of instrumentation, power, and density is determined by the severity and expanse of rhytidosis and the patient’s skin type. The erbium:yttrium-aluminum-garnet (Er:YAG) laser emits laser energy in the midinfrared light spectrum with a 2940 nm wavelength. This wavelength has 10 to 15 times more affinity for water than the carbon dioxide (CO₂) laser. Because its wavelength is at the peak of water absorption, it is a true epidermal ablation laser, producing only 5 to 20 μm of thermal damage.^9–11 Mild Er:YAG ablation may begin with topical anesthetic cream using 2 J/cm², a pattern 3, size 4, and one pass. This technique can be used for very mild rhytidosis and has minimal downtime. Additional passes and local anesthesia infiltration can be added for more profound rhytidosis. Three Er:YAG passes will ablate about the same depth of epithelium as one pass of the CO₂ laser will vaporize. Because the Er:YAG laser applications are more superficial with less transmission of thermal energy and no vasoablative properties, there is less erythema and more rapid healing; but Er:YAG laser treatments may be limited by bleeding, which rarely occurs with CO₂ laser resurfacing. Although theoretically the Er:YAG laser can ablate even very marked rhytids, the CO₂ laser is more effective for ameliorating severe photodamage and rhytidosis. There may also be a role for the combined use of CO₂ and Er:YAG resurfacing techniques. Ablating the epithelial debris with the Er:YAG between passes of the CO₂ laser may also have some benefit.

The Er:YAG laser may be used cautiously, with low fluences, on patients with darker skin types (Fitzpatrick III and IV). More darkly pigmented patients will frequently have a transient interval of postinflammatory hyperpigmentation beginning 2 to 4 weeks after the procedure. Topical antiinflammatory agents can be added after the second postprocedure week. Because the neck skin has fewer dermal appendages and reep-ithelializes slowly, it can also be treated, but with great caution, using lower fluences.

Perioperative Erbium:YAG Laser Care

Cleansing and lubrication are the key. Although the recovery time following Er:YAG ablation is significantly less and the sequelae less pronounced than following CO₂ laser resurfacing, the same general principles are followed in the perioperative period. Showering and hair shampooing with baby shampoo twice daily and using a vinegar face wash (1 tablespoon of white vinegar in 4 cups of lukewarm water) twice daily will keep the face clean and minimize crusting. Natragel masks are applied frequently to supplement cutaneous hydration.

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