Macrene Alexiades-Armenakas

The spectrum of laser skin resurfacing: nonablative, fractional, and ablative laser resurfacing.

UNLABELLED The drive to attain cosmetic facial enhancement with minimal risk and rapid recovery has inspired the field of nonsurgical skin rejuvenation. Laser resurfacing was introduced in the 1980s with continuous wave carbon dioxide (CO(2)) lasers; however, because of a high rate of side effects, including scarring, short-pulse, high-peak power, and rapidly scanned, focused-beam CO(2) lasers and normal-mode erbium-doped yttrium aluminium garnet lasers were developed, which remove skin in a precisely controlled manner. The prolonged 2-week recovery time and small but significant complication risk prompted the development of non-ablative and, more recently, fractional resurfacing in order to minimize risk and shorten recovery times. Nonablative resurfacing produces dermal thermal injury to improve rhytides and photodamage while preserving the epidermis. Fractional resurfacing thermally ablates microscopic columns of epidermal and dermal tissue in regularly spaced arrays over a fraction of the skin surface. This intermediate approach increases efficacy as compared to nonablative resurfacing, but with faster recovery as compared to ablative resurfacing. Neither nonablative nor fractional resurfacing produces results comparable to ablative laser skin resurfacing, but both have become much more popular than the latter because the risks of treatment are limited in the face of acceptable improvement. LEARNING OBJECTIVES At the completion of this learning activity, participants should be familiar with the spectrum of lasers and light technologies available for skin resurfacing, published studies of safety and efficacy, indications, methodologies, side effects, complications, and management.

Blinded, Randomized, Quantitative Grading Comparison of Minimally Invasive, Fractional Radiofrequency and Surgical Face-lift to Treat Skin Laxity

OBJECTIVES To quantify the improvements in laxity from the surgical face-lift and to perform a randomized, blinded comparison with the clinical effects of a novel, minimally invasive fractional radiofrequency (FRF) system. STUDY DESIGN Randomized, blinded, comparative trial. PATIENTS Fifteen sequential patients with facial skin laxity enrolled in the trial and completed FRF treatment and follow-up. Baseline and follow-up digital photographs of patients undergoing FRF were randomly mixed with 6 sets of baseline and follow-up images of patients undergoing surgical face-lift with equivalent baseline facial laxity grades. MAIN OUTCOME MEASURES Five independent blinded evaluators graded randomized baseline and 3- to 6-month follow-up photographs using a comprehensive quantitative 4-point laxity grading scale. Quantitative changes in laxity grades were calculated and compared statistically for FRF treatment vs surgical face-lifts. Patient satisfaction and adverse events were also evaluated. RESULTS Blinded grading of unmarked, randomized baseline and follow-up photographs of patients undergoing FRF treatment randomized with baseline and follow-up photographs of patients undergoing surgical face-lift demonstrated statistically significant improvement in facial laxity, with a mean grade improvement of 1.20 for patients in the surgical face-lift group and of 0.44 for FRF-treated patients on a 4-point laxity grading scale (P < .001). The improvements relative to baseline were 16% for FRF treatment compared with 49% for the surgical face-lift. The mean laxity improvement from a single FRF treatment was 37% that of the surgical face-lift. Patient satisfaction was high (dissatisfied, 0%; neutral, 7%; satisfied, 60%; and very satisfied, 33%). All participants in the FRF treatment group experienced transient erythema, mild edema, and mild to moderate purpura that resolved in 5 to 10 days, and they returned to normal activities within 24 hours. There were no adverse events or complications in the FRF group. All patients in the surgical face-lift group experienced scarring at surgical margins, erythema, edema, and ecchymosis, and they returned to normal activities on suture removal at 7 to 10 days. CONCLUSIONS This randomized, blinded, quantitative assessment using a validated grading scale of skin laxity improvement from the gold standard treatment, the surgical face-lift, and comparative analysis to a novel, minimally invasive FRF treatment has demonstrated 49% improvement in skin laxity relative to baseline for the surgical face-lift, compared with 16% for FRF. The surgical face-lift resulted in a mean 1.20-grade improvement on the 4-point laxity grading scale. In comparison, a single, minimally invasive FRF treatment demonstrated a 0.44-laxity grade improvement, or 37% that of the surgical face-lift, without the adverse effects and complications of surgical procedures. This study provides a basis for quantifying cosmetic outcomes from novel treatments with comparative analysis to the gold standard. It also suggests that minimally invasive FRF treatment may provide an important nonsurgical option for the treatment of facial skin laxity.

Unipolar radiofrequency treatment to improve the appearance of cellulite

Background: Previous studies suggest that radiofrequency (RF) energy may be effective as a treatment for cellulite. Objective: This bilateral paired blinded comparative study assesses the efficacy and safety of a unipolar RF device for improving the appearance of cellulite using a new quantitative cellulite grading system. Methods: In this randomized, blinded, split‐design study, 10 individuals (aged 32–57 years) with a clinically observable excess of subcutaneous fat and cellulite (minimum grade 2 out of 4) on the thighs received up to six unilateral treatments (number of treatments at the investigators discretion) at 2‐week intervals with unipolar RF. The untreated side of the thigh served as an internal control. Treated thighs were randomly assigned by alternate allocation. Results were evaluated using study participant questionnaires and by two blinded evaluators (JSD, KAA) using photographs and the authors (MAA) cellulite grading scale at each treatment visit and at 1‐month and 3‐month follow‐up visits after the final treatment. A novel quantitative four‐point cellulite grading system is presented and applied, which separately grades dimple density, dimple distribution, dimple depth, diameter and contour. Results: All participants responded to treatment (mean of 4.22 and range of three to six treatments). The blinded evaluations of photographs using the cellulite grading scale demonstrated the following mean grading scores for the treated leg versus the control leg: dimple density of 2.73 vs 3.18 (11.25% mean improvement), dimple distribution 2.89 vs 3.32 (10.75% mean improvement), dimple depth 1.47 vs 1.54 (2.5% mean improvement), and mean score of 2.36 (SEM 0.45) vs 2.68 (SEM 0.57) (8.00±2.84% mean improvement). The treatment was painless and side effects included minimal to moderate erythema which resolved within 1 to 3 hours. No crusting, scarring or dyspigmentation was observed. Conclusions: This randomized, blinded, split‐design, controlled study employing a quantitative four‐point grading scale demonstrated that this unipolar RF device is safe for the treatment of cellulite. Clinically visible and quantified improvement which did not achieve statistical significance but showed a trend toward improvement was observed in all patients following a mean of four treatments at 2‐week intervals.

Unipolar versus bipolar radiofrequency treatment of rhytides and laxity using a mobile painless delivery method.

Previous studies have shown that radiofrequency (RF) energy is a safe and effective treatment for rhytide‐reduction.

New Tattoo Approaches in Dermatology

Tattoos have fascinated mankind for centuries. Although these body marks were once considered to be permanent, technical and scientific progress in recent years has made it possible to remove tattoos by various treatment modalities. Contemporary technology involves the use of nonablative quality-switched lasers, which are considered to be the gold-standard treatment option for the removal of unwanted tattoo ink. Current research in the field of tattoo removal is focused on faster lasers and more effective targeting of tattoo pigment particles including picosecond laser devices, multi-pass treatments, dermal scatter reduction, application of imiquimod, and the use of microencapsulated tattoo ink.

Bipolar and multipolar radiofrequency.

BACKGROUND The increased demand for anti-aging treatments over the past decade has fueled the development of multimodality devices. This allows for more efficacious treatment of dermal defects, excess adiposity, and skin laxity. Radiofrequency (RF) devices are constantly evolving and consequently adding multiple indications for their use. In this article, the authors focus on bipolar and multipolar RF modalities. OBJECTIVE The objective was to review, summarize, and evaluate the key studies of procedural therapies using bipolar and multipolar RF technologies. METHODS Studies selected for evaluation had clear statements of purpose, patient selection, follow-up evaluations, previous and concurrent medications, treatment parameters, methods for evaluating results, and adverse effects. All studies were complete and published in peer-reviewed journals. RESULTS AND CONCLUSION With their unique mechanism of action, bipolar and multipolar RF devices remain versatile treatment options associated with minimal downtime and pain compared with monopolar RF and other nonablative modalities. Proper patient selection and education along with an experienced treating physician is crucial in achieving patient satisfaction and results. It is important that larger studies are conducted to provide data on upcoming devices. Review of the literature provides a starting point for physicians seeking to treat patients safely and effectively with newer devices.

Prospective Multicenter Clinical Trial of a Minimally Invasive Temperature-Controlled Bipolar Fractional Radiofrequency System for Rhytid and Laxity Treatment

BACKGROUND A minimally invasive fractional bipolar radiofrequency (FRF) was developed. OBJECTIVE To evaluate safety and efficacy of FRF in reducing face and neck rhytides and laxity. MATERIALS AND METHODS This prospective, open‐label, multicenter clinical trial enrolled 100 subjects with mild to severe facial and neck rhytides and laxity at seven centers in a per‐protocol analysis. One single‐pass FRF treatment was administered through five 32 g‐needle electrode pairs at a preselected real‐time fixed temperature of 62 to 78°C, energy duration for 3 to 5 seconds, and impedance restrictions of 200 to 3,000 Ohms, ensuring intradermal delivery. Five blinded dermatologists and plastic surgeons graded randomized standardized baseline and follow‐up photographs of 53 and 42 subjects at 3‐ and 6‐month follow‐up intervals, respectively, using the Fitzpatrick wrinkle and Alexiades‐Armenakas laxity scales. Subject assessments and adverse events were recorded in 100 subjects. RESULTS Blinded evaluations revealed correct pre‐ and post‐treatment identification in 100% of scored cases, mean improvement of 25.6% on the Fitzpatrick Wrinkle Scale and 24.1% on the Alexiades‐Armenakas laxity scale at 6 months, and 100% response rate for rhytides and 95% for laxity. Subgroup analysis revealed maximal rhytid reduction in the mean target temperature of 66.7, energy duration of 4.2 seconds, and volume of denatured collagen of mm3 denatured collagen group. Adverse events included transient erythema, edema, and ecchymoses, resolving within 1 to 5 days, and two incidents of temporary pinpoint depressions. More than 90% of subjects were satisfied or very satisfied. CONCLUSION Real‐time temperature‐controlled FRF is a highly reproducible, safe, effective nonsurgical treatment of face and neck rhytides and laxity and provides important insights into neocollagenesis, neoelastogenesis, and clinical outcomes.

Combination Laser-Assisted Liposuction and Minimally Invasive Skin Tightening with Temperature Feedback for Treatment of the Submentum and Neck

BACKGROUND There is need for better nonsurgical treatment of excessive neck fat and skin laxity. OBJECTIVE To assess combination laser‐assisted liposuction (LAL) and minimally invasive skin tightening (MIST) of the submentum and neck under direct temperature control. DESIGN Randomized, prospective, three‐arm study of single LAL‐MIST treatment comparing 1,064, 1,319 nm, and blended 1,064 and 1,319 nm. METHODS Twelve subjects were randomized to three arms. LAL was fiber administered into the adipose layer, followed by aspiration. MIST was laser fiber administered into the subdermal plane. Multiple passes were administered until uniform 45–48°C was attained in the targeted plane. Energy delivery totalled 5,000–7,000 J. Subjects were photographed at baseline and 1, 2, 3, 4, 5, and 6 months after treatment and assessed using a 4‐point quantitative laxity grading scale and fat aspirate quantitation. RESULTS Mean ± standard deviation baseline, follow‐up, and difference in laxity grades and percentage improvement over baseline for the three study arms and total were 3.19 ± 0.38%, 1.88 ± 0.85%, 1.31 ± 0.55%, and 43.8 ± 18.5%, respectively, for 1,064 nm; 3.75 ± 0.29%, 2.38 ± 0.25%, 1.38 ± 0.25%, and 36.6 ± 5.9%, respectively, for 1,319 nm; 3.38 ± 0.48%, 2.13 ± 0.63%, 1.25 ± 0.29%, and 39.3 ± 12.9%, respectively, for 1,064/1,319 nm; and 3.44 ± 0.43%, 2.13 ± 0.61%, 1.31 ± 0.36%, and 39.4 ± 12.1%, respectively, total. Mean fat aspirate volumes were 6.13 ± 3.28 mL for 1,064 nm, 8.25 ± 2.50 mL for 1,319 nm, and 6.50 ± 5.74 mL for 1,064/1,319 nm. Clinical improvement was consistent across all subjects; all before‐and‐after photographs are presented (save a recognizable subject for privacy). No blistering, scarring, or dyspigmentation was observed. CONCLUSION Combination temperature‐controlled LAL‐MIST treats excess fat and skin laxity of the submentum and neck with excellent safety and efficacy.

The Future of Photodynamic Therapy

The field of PDT is increasing its accuracy at targeting specific tissues, organisms, and other matter for ever-advancing applications in therapeutics. Of importance is the broadening of the classes of photosensitizers that are being developed for use in PDT, along with the development of novel wavelengths and light sources. Technologically advanced, microtargeted delivery systems are being developed that will enable photosensitizers to penetrate to desired targets with increasing specificity and efficiency. Finally, the applications of PDT to various clinical conditions are advancing, with the advent of its use for the treatment of acne, light hair removal, and infections.

Photodynamic Therapy for Acne, Rejuvenation, and Hair Removal

Publisher Summary This chapter discusses the photodynamic therapy for acne, rejuvenation, and hair removal. Photodynamic therapy (PDT) is a century-old treatment for neoplastic conditions, which most recently has evolved to treat acne and photoaging. PDT is often used for therapeutic challenges. Basic science studies indicate that topical ALA results in preferential accumulation of PpIX in hair follicles, with highest expression during the anagen phase. This makes actively growing hair susceptible to light-mediated destruction, as shown in rodent models. Clinical studies are needed in order to determine whether this would be a viable mode of hair removal, provided the protocol is optimized to maintain the efficacy of hair follicle destruction without the risk of significant side effects and complications. There was only one published clinical study regarding the use of PDT for hair disorders in humans aimed at treating the hair-loss disease alopecia areata with topical ALA followed by red light. PDT has been used to treat cutaneous neoplasia, and recently this application has been extended to include photoaging, the cutaneous manifestation of sun-induced aging to the skin. The current protocols in use involve the topical application of ALA for short incubation followed by blue light, LP PDL, or IPL. Among these light sources, IPL is the best studied and most obvious choice, since it has well-demonstrated efficacy in photorejuvenation, which is augmented with antecedent ALA application.