8 Use of Light- and Energy-Based Therapies with Cosmetic Surgery

8.1 Introduction

One’s perceived aesthetic appearance is based in part on the amount of redundant skin, the impact of the underlying supporting structures, and the quality of the skin itself. Although surgeons often focus on the skin envelope and supporting structures, the remaining skin has changed from its original, youthful manifestation. Signs of this change are evident through undesirable hyperpigmentation and hypopigmentation, hypervascularity, fine wrinkles, and items difficult to quantify such as skin pore size and texture ( Fig. 8.1). To date, light- and energy-based therapies (LAEBT) have not been shown to provide skin tightening that parallels the results obtained through surgery. However, LAEBT can significantly improve patient satisfaction regarding their appearance after surgery. They also provide nonsurgical options, which would allow the treating clinician to improve the patient’s appearance.

The etiology of the signs of skin aging is multifactorial. An acknowledged source of skin damage is the effect of ionizing radiation from the sun. Despite medical advice, many patients still do not wear sunscreen or do not apply them as directed. The cumulative impact of the sun’s radiation on unprotected skin can cause dyschromia.¹

A genetic component also factors into one’s aging process. Not all individuals age the same way given parallel environmental exposure. Systemic conditions such as diabetes, scleroderma, or other connective tissue disorders impact the appearance of one’s skin and the ability to heal.² Cystic acne during adolescence can leave scars that may become more unsightly as one ages.^3,4 Hormonal changes can affect the appearance of an individual’s skin.⁵

Even one’s lifestyle beyond the harmful effects of the sun’s radiation can impact the aging process of the skin. Smoking is harmful to the skin and wound healing.⁶ Proper skin hygiene can mitigate the signs of aging by keeping skin pores open and minimizing unwanted melanin in the epidermis. Individuals trying to optimize the appearance of their skin spend millions of dollars using over-the-counter, topical agents that do not have peer review papers substantiating their efficacy.

Fig. 8.1 This is a good representation of a graphic example of the difference between younger and older skin.

Once a surgical procedure has been performed, skin laxity and the underlying support structures have been corrected. The ancillary use of LAEBT can enhance the appearance of the remaining facial skin by improving its color and texture. Such therapies can also be used on nonfacial regions. Frequently patients do not want surgery. In this clinical setting, utilizing LAEBT can significantly improve one’s appearance.

8.2 Patient Selection

8.2.1 Safety

Many LAEBTs rely on the energy being focused to a chromophore, which can be water, melanin, and/or hemoglobin ( Fig. 8.2). When a patient presents with a “tan,” they should be given the option to wait until the tan fades before initiating treatment if the energy source efficacy is impacted by skin color. This way, the energy that is intended for undesirable melanin will not be drawn to the skin pigment because of the transient tan. Patients with hypervascularity should be advised to avoid anything that would cause vasodilatation prior to treatment. If a patient has a hypersensitivity to sunlight, using a device that provides light energy as a therapeutic modality should not be recommended.²

Patients who have taken recent medications such as isotretinoin or oral antibiotics, which are known to cause hyperpigmentation, should have their aesthetic treatment delayed until the systemic effects of these medications have expired. Even nonprescribed medications such as St. John’s Wort can negatively impact the final outcome, because the use of such a nonprescribed medication can contribute to hyperpigmentation. Prescribed medications such as Coumadin (warfarin, Bristol-Myers Squibb Company) or over-the-counter medications that impact the coagulation cascade should be stopped prior to treatment if it would not compromise the patient’s health to minimize the potential complication of bruising ( Table 8.1 and Table 8.2). Pregnancy is a “relative” contraindication. Most companies have not performed studies that demonstrate safety in such a clinical setting.

Patients with active autoimmune or connective tissue disorders should not be treated.⁷ However, patients with stable lupus may still have unwanted skin redness once their condition becomes stable and they are not receiving treatment for their medical condition. Good results can be obtained in terms of improving residual hypervascularity.

Fig. 8.2 Relative absorption of light energy and the various types of laser energy.

Table 8.1 Medications that may complicate LAEBT*

*When taken 2 weeks before surgery

**Or any type of anti-inflammatory medication

The treatment of patients with a history of wound-healing problems, such as keloid and hypertrophic scarring, needs to be evaluated to determine why such conditions occurred. Hypertrophic scarring can occur after burn injuries and can be improved with ablative technology and or pulsed light treatments.8 Potentially cancerous skin lesions in the treatment area should be biopsied prior to addressing aesthetic concerns. In contrast, benign conditions such as actinic keratosis can be treated with LAEBT, cryotherapy, or other modalities.

As part of patient safety, topics to include in an informed consent for LAEBT are prolonged redness, transient “speckling” (hyperpigmentation), scabbing, edema, hair loss, purpura, hyperpigmentation, hypopigmentation, bruising, activation of a cutaneous herpetic skin eruption, infection, scarring, and dissatisfaction. In general, the more ablative the device, the greater the potential for these adverse side effects.

Table 8.2 Supplements that may impact LAEBT adversely*

*When taken 2 weeks before surgery

8.2.2 Analysis of the Skin

It is very important to address the individual’s skin color. The gold standard for rating skin color is the Fitzpatrick scale7( Fig. 8.3). Patients with a lighter skin color (Fitzpatrick I–III) are easier to treat when dealing with dyschromia, because the adjacent, untreated skin does not have as much innate pigment, allowing for an easier “blending” to the untreated region. Patients with Fitzpatrick skin types IV–VI can be treated successfully with LAEBT. To minimize the chance of posttreatment hyperpigmentation, these patients should be pretreated with a bleaching cream such as hydroquinone or kojic acid.⁸ These topical agents should be continued until the patient has obtained his or her optimized, final skin color. Patients with a history of herpetic skin breakouts in the treatment area should be prescribed antiviral medication, which should be continued until the patient has fully recovered.

Determining the basis of the dyschromia is a critical component to providing optimal care. Hyperpigmentation is the most common manifestation of the aging process of the skin; this can consist of isolated spots or an overall yellow or brown discoloration on the skin. When hyperpigmentation manifests as overall yellow or brown skin discoloration, it can hinder identifying the underlying hypervascularity as the redness is camouflaged. Reducing the undesirable brown skin discoloration will reveal this vascular problem. Thus, a thorough evaluation of the skin regarding the desired improvement in hyperpigmentation, hypervascularity, and skin wrinkling is needed prior to selecting the best modality for treatment.

It is important to appreciate the various densities of the undesirable chromophore or skin rhytides, which can vary within the treatment region. Patients with rosacea often have a prominence of hypervascularity in the malar region. Not adjusting device parameters in response to chromophore density may result in a complication or inadequate results. The perioral and orbital regions are often left with skin wrinkles after a successful surgical procedure. Ablative energy may reduce these signs of aging. To optimize ablative therapy in areas with deeper skin wrinkles, a second or third pass is often needed.

The patient’s age also can influence the treatment parameters and outcome. Parameters successfully used treating individuals in their thirties may need to be adjusted for those who are 50 to 60 years of age due in part to a thinning of the dermis, wound healing, and concomitant medical conditions.

The location of the treatment is also an important consideration. Although the desired results are similar to those for facial skin, the device settings used for facial skin may need to be adjusted when treating the skin on the neck, chest, or hands. Depending on the technology used, the recovery process can be more difficult when treating nonfacial skin.⁹

Fig. 8.3 The Fitzpatrick scale. Assessing skin color is an important factor when treating a patient’s skin. The clinician should be aware that certain individuals, such as those from Asian or Mediterranean descent, may present with a skin type II or III but react like a skin type IV person. Thus, establishing their “tanning” history is important. Starting with lower energy settings and doing a “test patch” may be prudent to avoid complications. (Adapted with permission from Fitzpatrick, T. B. “Soleil et peau” [Sun and skin]. Journal de Médecine Esthétique (in French) (2): 33–34) 1975)

8.2.3 Understanding the Technology

8.2.4 Combining Modalities

As clinicians understand LAEBT, their limitations, and how to avoid complications, combining different modalities may enhance outcomes. Photorejuvenation following ablative therapy can be helpful with blending to adjacent skin areas. Providing radiofrequency (RF) treatments to the perioral or periorbital regions can smooth skin wrinkles following the improvement in dyschromia through photorejuvenation.10,11 During the recovery process after ablative therapy, affording patients photorejuvenation treatments with the fluence reduced and selecting a cutoff filter that delivers energy primarily directed toward red can shorten the recovery time.

8.3 Pretreatment and Posttreatment Protocols

8.4 Incorporating Nonsurgical LAEBT

8.4.1 Ablative Therapy

Prior to the early 1990s, chemical peels and dermabrasion were the mainstay of topical, nonincisional treatment for wrinkles and unwanted brown spots. These modalities are still used effectively. The implementation of lasers to treat hyperpigmentation and skin wrinkling became popular in the early 1990s.8Usually lasers provide a single, collimated wavelength delivered to the skin. The primary wavelengths used for laser skin resurfacing are CO₂ (10,600 nm) or erbium YAG (2,940 nm). The dynamic ability to control the depth of injury through the device settings during treatment enhanced the use of lasers compared to topical chemical agents. The “target” of the energy is the water content within the skin. The evolution of laser therapy has been focused on minimizing the recovery period by reducing the initial zones of injury. Providing smaller focal injury spots and delivering laser energy in a scattered pattern has helped shorten recovery times and treatment discomfort. This modification may require more than one treatment to provide parallel results, however. Depending on the amount, density, and pattern of the energy delivered, lasting results may be seen after one to three treatments. In general, the greater the energy delivered and the higher the density, the longer the recovery for each treatment ( Fig. 8.4). The end point for a fully ablative single treatment is a light tan skin color. When providing less energy to the skin, hyperemia may reflect the desired initial skin reaction.

Initial recovery times can be short, 2–3 days or longer, for 3–8 weeks. Multiple laser treatments may be required when patients opt for shorter recovery periods. Typically, there is some initial skin crusting, because the energy penetrates into the dermis and ablates tissue within the zone of injury. Post-treatment protocols may parallel the protocols provided to individuals with second-degree burns, including topical creams and or bandages. Camouflage makeup can be applied once the skin is healed. Treatment analgesia is customized to the fluence, the density of the energy delivered, and the energy wavelength, and it can range from topical analgesics with oral supplementation to general anesthesia.

In terms of the wavelengths for each laser, it is CO₂ or erbium for the fully ablative image, erbium for the nonablative fractional resurfacing, and CO₂ for the ablative fractional resurfacing. The ideal patient does not have underlying redness but is looking for an improvement in skin wrinkling and hyperpigmentation. Removing the undesirable “brown” skin color may reveal pre-existing redness that was masked by the unwanted melanin in the epidermis. Because of the potential for hypopigmentation posttreatment, treating patients with Fitzpatrick skin type IV–VI requires a modification of one’s protocol for treating skin types II–III. Being able to “blend” the treated area to the adjacent skin by altering the energy settings or delivery pattern is important. The need to adjust the pattern and amount of energy delivered also needs to be considered when treating regional areas, such as the perioral and periorbital regions, which are often left with wrinkles following a rhytidectomy or blepharoplasty.

Clinical Results

This woman had a facelift performed by another physician. Her concerns were the residual fine wrinkling and brown spots on her face ( Fig. 8.5a). She underwent full-face, CO₂ laser skin resurfacing. The clinical end point of laser treatment on the deep wrinkles was a chamois color of the skin. Other regions without such deep wrinkles had skin erythema as the treatment end point. Two years after this treatment, this woman had smoother skin and a reduction in her hyperpigmentation ( Fig. 8.5b). As she continued to age, she received periodic neurotoxin injections on her forehead and in the lateral orbital and perioral regions. She has maintained an improvement in her skin color and wrinkle reductions using this protocol, as shown 5 years ( Fig. 8.5c) and 10 years ( Fig. 8.5d) after her ablative treatment.

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