18. Nonablative Laser Resurfacing

Ibrahim Khansa, Molly Burns Austin, Alton Jay Burns

EQUIPMENT

Two types of nonablative lasers, and two additional modalities, are commonly used in nonablative resurfacing.

MIDINFRARED LASERS

■ Longer wavelength allows deeper penetration into the dermis and partially spares melanin.

■ Target dermis without a specific chromophore

■ Not very effective for epidermal signs of photoaging, such as dyschromia

ND:YAG LASER

■ 1320 nm, long pulses

■ One of the earliest lasers used for nonablative resurfacing

• Early applications did not include a cooling device, and this resulted in a high rate of scarring, hyperpigmentation, and pain.

■ Newer models include a cryogenic cooling spray, which keeps the epidermis temperature around 40°-48° C, while the dermis is heated to 60°-70° C.^1,2

■ Effective in resurfacing atrophic acne scars^3,4

Q-SWITCHED ND:YAG LASER

■ 1064 nm, very short pulses

■ Coupled with a cryogenic cooling device

■ Very effective at treating tatoos⁵

DIODE LASER

■ 1450 nm

■ Has not demonstrated a significant effect on rhytids⁶

■ Effective in resurfacing atrophic acne scars⁷

ERBIUM-DOPED FRACTIONAL LASER

■ Fraxel (Solta Medical)

■ 1550 nm

■ The most frequently used nonablative laser and has multiple applications, such as dyschromia,^8,9 fine rhytids,^8,9 acne scars,¹⁰ burn scars,^8,9,11 striae distensae¹²

■ Treatment of dyschromia: Same effectiveness as nonablative, nonfractionated lasers^13,14

■ Treatment of rhytids: More effective than nonfractionated, nonablative lasers, but less effective than ablative fractional or fully ablative lasers13,14

■ Requires three to six treatments, spaced at 2- to 4-week minimum intervals

■ Other fractional lasers include the Lux 1540 fractional laser (1540 nm, Cynosure) and the Affirm laser (1320 nm + 1440 nm, Cynosure).¹⁵

VISIBLE LIGHT LASERS

■ Pulsed dye laser

• 585-595 nm

• Of limited use in dark skin types because of high affinity for melanin

► Risk of hypopigmentation and hyperpigmentation

• Shown to increase the quantity of collagen and elastin in the dermis¹⁶

• Photodynamic therapy: Effect can be potentiated by topical application of a photosensitizer, such as 5-aminolevulinic acid.¹⁷

• For aging treatment, fluencies used are below those typically used for the treatment of vascular lesions, and pulse width durations are longer than those used to treat port-wine stains to minimize purpura.

• Best used for signs of hypervascularity and dyschromia

• Most effective laser for port-wine stain treatment

INTENSE PULSED LIGHT

■ Not a laser. Intense polychromatic light including multiple wavelengths from 500-1200 nm.¹⁸

■ Filters can be added to allow only certain wavelengths, thus targeting specific chromophores.

■ Of limited use in dark skin types (IV-VI) because of affinity for melanin

■ Excellent in the treatment of hypervascularity, such as rosacea and telangiectasia¹⁹

• Very good in the treatment of dyspigmentation, such as solar lentigines¹³

• Broadband light (BBL) is a form of IPL and has proven to be effective in genetic transcription to a more youthful genomic expression with multiple frequent treatments at least three times per year for several years²⁰

■ Photodynamic therapy: Effect can be potentiated by topical application of a photosensitizer, such as 5-aminolevulinic acid.²¹

RADIOFREQUENCY

■ ThermaCool (Solta Medical)

• Radiofrequency waves cause collagen denaturation when heated to 55°-62° C, and the amount of collagen in the skin increases over time.²²

• Amount of tissue heating and the placement of that heating zone can be controlled by modifying the fluence of the radiofrequency waves and the intensity of the cryogenic cooling spray.

• Heat is delivered at high fluence (70-150 J/cm²) for short pulses (<2.3 seconds) (flash heating).

► However, most studies were not blinded, randomized, or comparative.12,23

► Overall, results were modest and inconsistent.^24,25

• Can be painful to the patient

• Low risk of complications, although multiple reports have described fat atrophy from heat damage to adipose tissue early in the treatment’s evolution.²⁶ Current treatment protocols greatly minimize or eliminate this risk.

TECHNIQUE

ANESTHESIA

■ Nonablative lasers are not as painful as ablative lasers in general, but can vary depending on the depth; i.e., a deep, nonablative laser treatment could possibly cause more pain than a superficial ablative laser treatment.

■ Topical anesthesia, typically with EMLA (2.5% prilocaine/2.5% lidocaine) or LMX (4% or 5% lidocaine), is usually sufficient.

■ It must be applied at least 1 hour before treatment, covered with an occlusive dressing, and wiped off just before treatment.

SAFETY

■ Medical lasers are all class IV devices.

• They are hazardous to view directly, under reflection or under scatter.

• Therefore all persons in the room must wear wavelength-specific safety goggles.

• A warning sign must be placed on each entrance, with extra goggles hanging outside the door.

■ Corneal eye shields are placed, with ophthalmic ointment lubrication.

■ If patient is under general anesthesia, a laser-safe ET tube must be used if treating around the mouth, and the lowest possible FiO₂ should be given.

• Wet towels should be applied around the treatment area to absorb heat energy.

■ If treating viral warts, live viral particles can be transmitted into personnel’s airway.

• Therefore appropriate masks and ventilation systems must be in place.

TECHNIQUE

■ During the first treatment, inexperienced users can start with a test area to find the optimal fluence for the patient’s skin; however, the use of test spots is very unusual beyond a novice level of experience.

• Clinical endpoints for nonablative lasers are usually based on guidelines determined by experts and depend on the treatment goal. There is usually no visual endpoint for nonablative lasers used for the treatment of rhytids.

► Hypervascularity: Mild purpura

► Tattoo removal: Skin whitening

■ In subsequent treatments, the choice of fluence can be made based on the effect observed with prior treatments.

■ Multiple passes may be needed before the clinical endpoint is observed.

■ Perioral rhytids are difficult to improve and may require fully ablative lasers and/or soft tissue fillers.27

Scars

■ Nonablative and fractional lasers are effective at improving burn scars, traumatic scars, and unfavorable, hypertrophic surgical scars, but require multiple treatments.

■ Multiple modalities may be combined to treat different aspects of the scar:

• Fractional laser for scar pliability, texture²⁸

• PDL for erythema and irritation of immature scar^29,30,31,32

• IPL for chronic folliculitis, scar dyschromia³³

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