 Michael H. Gold,
M.D.
Clinical Assistant Professor, Vanderbilt University
Gold Skin Care Center, Tennessee Clinical Research Center
Nashville, USA.
Over the past several
years, there has been an
explosive growth in cosmetic æsthetic
procedures in the dermatology arena. More
and more clinicians are performing these
procedures and we have more and more
choices and options available for our
patients looking for new and safe cosmetic
procedures, all with as little downtime for
our patients as possible.
The explosion on æsthetic dermatology
and cosmetic surgery can be traced to the
surge in the cosmetic use of botulinum toxin
A. Since Botox has become widespread in its
availability and use, other cosmetic
procedures, utilizing fillers and energy based
systems (lasers, light sources, and
radiofrequency devices) have been
developed at a fairly intense pace to keep up
with this demand in cosmetic procedures
available for our patients. The purpose of
this manuscript is to review some of the
newer developments in aæsthetic cosmetic
dermatology and to demonstrate how far
we have come in offering these newer non-
invasive cosmetic procedures to our patients.
Lasers and light
sources
Lasers and light sources are not new.
What is new is that these devices have
evolved and are much safer in today’s
environment compared with their earlier
counterparts with results being delivered
which are unparalleled in the laser business.
All of our therapies today are geared
towards providing results closer to true
ablative resurfacing without the downtime
and potential adverse events seen with true
ablative resurfacing. Ablative resurfacing is
the gold standard in rejuvenation of the skin
with lasers and light sources; newer
modalities are approaching this with less
downtime.
Intense Pulsed Light Sources
Intense pulsed light (IPL) sources have
become the standard for photorejuvenation
over the past several years. IPLs are broad
band sources of light which utilize cut-off
filters to filter out light which are not necessary for an effect to be seen in the
tissues. IPLs have documented efficacy in
treating vascular and pigmented concerns in
the skin, and also have been shown to affect
the collagen and elastic tissue fibers in the
dermis giving an overall rejuvenation effect.
The term photorejuvenation was created to
describe the positive skin changes seen after
a series of IPL treatments – improvement in
the red, brown, and texture and tone over
time with minimal downtime have made IPLs
very popular in the laser/light source world.
IPL™ Photorejuvenation. Before and after 4 IPL Treatments. Courtesy of David J. Goldberg, MD Westwood, New Jersey |
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IPL™ Photorejuvenation. Elastin Stain before and after IPL treatment 200x. Courtesy of B. Zelickson MD |
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IPLs are much more sophisticated in
today’s environment, with much better
computer software packages, better pulsing
techniques as compared to their earlier
counterparts, and have much improved
epidermal cooling, making them safe and
effective for photorejuvenation. Many IPLs
exist and there are differences amongst the
devices. Physicians must utilize IPLs from
reliable companies with proper technical
support when deciding on purchasing an IPL.
Non-Ablative Laser Resurfacing
plus Fractional Resurfacing
Non-ablative laser resurfacing has
become a popular laser option with the
advent of lasers in the near infrared
spectrum of light. These laser systems work
on the collagen in the upper dermis and
have resulted in patients with fewer wrinkles
and rhytids following the therapy. Several
treatments are usually required for an effect
to be seen, and although sometimes difficult
to document, patients have been generally
satisfied with the results they receive.
Adverse effects are minimal, with erythema
and edema common; scarring and
pigmentary changes fairly rare.
The Market. Procedure Volume Expected to Continue Dramatic Growth. Millenium Research Group 2006 |
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Because many have difficulty
documenting success with the non-
ablative infrared laser systems, resurfacing
of today has evolved into a world known
as fractional resurfacing, in which lasers
damage areas of the skin with skip areas
in between. This fractionated effect has
transformed today’s laser business and
most laser companies are working
feverishly to develop fractionated laser
systems which can deliver energy at
various depths into the skin, with skip
areas, to have a positive effect on the skin.
In doing so, we are achieving better
resurfacing than the non-ablative lasers
and we are approaching a more, truer
ablative device with less downtime.
Fractionated laser systems are now
divided into non-ablative fractionated
resurfacing and ablative fractionated
resurfacing. The non-ablative
fractionated laser devices utilize infrared
laser energy to create dermal damage
with epidermal sparing. The damaged
areas of the dermis heal via the normal
wound healing cascade within the skin
and with the help of the normal adjacent
skin; the resultant rejuvenation skin has
demonstrated very acceptable cosmetic
results. There are many non-ablative
fractionated laser systems on the market
and they all work in a similar fashion.
These non-ablative fractionated laser
systems are being utilized for the
treatment of fine lines and wrinkles, acne
and traumatic scars, pigmentary concerns
including melasma, and newer indications
are being found on an ongoing basis. The
non-ablative fractionated laser systems
work via a series of treatments, most
requiring 4-6 treatments to see the
desired results. Downtime has been found
to be minimal with these treatments and
adverse events minimal.
To counter the number of treatments
required with the non-ablative
fractionated laser systems, and for those
requesting more aggressive fractionated
laser systems, laser companies have shifted
to what is typically known as the ablative
fractionated laser systems, and the most
current research in this field is focusing on
these ablative fractionated laser systems.
The ablative fractionated laser systems are
based on erbium YAG laser systems and
the CO2 laser systems. These systems produce true epidermal and dermal injury
with skip areas of normal skin producing
the fractionated effects. The advantages
of ablative fractionated laser systems is
that they give the desired results in a
much faster approach, with one or two
treatments usually required. However,
with all the systems, there is more
downtime associated with these
treatments, usually from 3-5 days needed.
Fractionated laser systems have been a
boon for the laser industry. These devices
are providing rejuvenation closer to the
original ablative resurfacing than ever
seen before. As we delve more and more
into the ablative world, we must keep in
mind that as we become more and more
aggressive, potentials for problems will
become more pronounced; i.e., these
devices need to be utilized by skilled
providers who understand tissue-tissue
laser interactions and are familiar with the
skin and wound healing characteristics
that make these devices special.
Skin Tightening Systems
The next major advance in laser and
“energy” based systems are the skin
tightening devices. Whether through
radiofrequency (RF) delivery systems or
through broad band infrared light
systems, these medical devices work
through the premise that if there is deep
dermal heating through the targeting of
water deep in the dermis, collagen
denaturation followed by collagen repair
and ultimate skin tightening will occur.
This skin tightening has been seen to
occur over time, thus alleviating the need
for more aggressive surgical procedures in
many of our patients.
The skin tightening systems began with
monopolar RF, where RF energy is
delivered to the skin with a grounding
plate at another site on the skin far from
where the RF energy is given. The
treatments have resulted in tissue
tightening in many individuals and are
still the standard for all of the other skin
tightening devices on the market or being
developed. Recently, bipolar RF, either
through the use of a vacuum apparatus to
deliver the energy to specific targets deep
in the dermis, or with bipolar RF with
another laser/light source to affect the
deeper tissues, skin tightening can be
achieved. Unipolar RF, where the ground
is built into the handpiece, are also being
utilized and newer tripolar devices are
being evaluated.
Skin tightening devices have provided
very acceptable results in many patients.
Most feel that not everyone will respond
to these therapies and it is difficult to
determine which patients respond best to
these therapies. But for those not
wanting a more aggressive surgical
procedure or who are not candidates for
those surgeries, these skin tightening
devices may be the answer.
Body Countering and Cellulite
Body contouring and cellulite therapy
are perhaps the final frontier in laser and
energy based systems which has seen laser
companies scrambling to design systems
which can have an effect on the fat and
cellulite. These laser and energy based
systems which contour fat and have an
effect on cellulite vary from low powered
laser based systems utilizing mechanical
massage and vacuums with the laser light
to more aggressive RF systems to even
more aggressive laser lipolysis with
traditional liposuction to ultrasound
devices (not FDA approved) all designed to
reduce the amount of fat and potentially
tighten skin. Laser lipolysis is a fascinating
concept to liquefy the fat prior to
traditional liposuction; and with the laser
itself, produce tissue tightening at the
same time.
Botulinum Toxin A
Medical devices are a big part of æsthetic
cosmetic dermatology, but remember, this
discussion started by making mention of
botulinum toxin A. Botulinum toxin A is
perhaps, one of the most significant
advances in modern dermatology that we
have seen, being able to treat fine lines and
wrinkles in a very safe and efficacious
manner. Botox has been around medicine
for quite some time but it was not until the
late 1980s and early 1990s did clinicians first
noticed its effects on wrinkles while treating
ophthalmic disorders. Controlled clinical
trials performed showed the safety and
efficacy of utilizing Botox for the treatment
of glabellar lines and wrinkles and a whole
field of cosmetic dermatology came to age.
Further advances in injection technique and
expanded indications, although none FDA
approved except for glabellar wrinkles, has
made Botox the number one cosmetic
procedure in the world. More clinicians are
utilizing Botox in their practices and this has
led to further increases in æsthetic cosmetic
procedures.
Several brands of Botox are available and
all are a little different in their speed to
onset, duration of effect, and in their
concentrations needed as compared to the
original Botox. Clinicians should be aware of
these other forms of botulinum toxin A and
utilize those formulations they feel most
comfortable with. Most would recommend
that only products which are FDA approved
be used in the US market and those that are
CE marked be utilized in Europe. Other
forms of botulinum toxin may be available
but may also have deleterious effects if not
used appropriately. Therefore, only
approved products should be given to our
patients.
Fillers
With the increased use of Botox, we have
also seen an increase in the kinds of, and use
of fillers for soft tissue augmentation.
Twenty years or so ago, dermatologists
utilized collagen injectable material for soft
tissue augmentation. Skin testing was
required and most patients saw durations of
effects for approximately 3-6 months before
the material was absorbed. Aesthetic
cosmetic dermatology demanded better and
we have been given a variety of fillers which
have been very rewarding to those using
these new products.
Today, the hyaluronic acids (HA) fillers
make up the majority of filler products being
utilized in æsthetic cosmetic dermatology. A
variety of HA filler products are available for
us to use – and the duration of effect varies
from 6-12 months for most of these HA
fillers. HA fillers require no pre-skin tests
before injecting and do not require over-
correction, as did the collagens which
preceded them. Some patients do notice some erythema and edema after injections
which can last up to a day or so after the
injection, and some complain of pain upon
injection. Newer HAs are being developed
with lidocaine, to alleviate the discomfort,
and with better flow characteristics, which
minimizes any potential post-injection
erythema or edema. HAs of today are safe,
effective and a wonderful addition to our
filler inventory.
Other fillers also exist. Poly-L-lactic acid is
FDA approved for volume enhancement in
HIV positive individuals. A skin test for it is
not required. It is used off-label as a volume
replacement in many cosmetic patients. A
series of injections is required to achieve the
final result, but once achieved, many
patients see a duration of effect of upward
of two years. Calcium hydroxyapetite is also
being routinely used as a soft tissue filling
agent. It also does not require a skin test
prior to injection. Duration of effect with
this product is at least one year and it is
being used to fill lines and wrinkles and for
volume replacement as well. Other fillers,
including a new porcine collagen derivative
are also being developed, and newer HAs are
also being created, all with the intention of
giving patients new options for soft tissue
augmentation.
Conclusion
Aesthetic cosmetic dermatology has
grown and matured steadily over the past
several years. Our machines, toxins, and
fillers have aided us in achieving wonderful results with minimal downtime which
translates into happy and satisfied patients,
making this a very rewarding specialty at this
period of time.
Dermatologists are the skin experts and
we need to make sure that we constantly
stay ahead of the curve in working with
companies to develop new products and
devices, and to make sure that we have the
science to back up the claims for these new
products.
We are in a great time in æsthetic
cosmetic dermatology – we need to keep
growing, learning, and performing
procedures for the benefit of our patients. |
