Adapted from Lumenis. IPL indicates intense pulsed light.
Britt CJ, Marcus B. Energy-Based Facial RejuvenationAdvances in Diagnosis and Treatment. JAMA Facial Plast Surg. Published online December 01, 2016. doi:10.1001/jamafacial.2016.1435
What advances in diagnosis, prevention, and management of energy-based facial rejuvenation have been introduced in the past 5 years?
In this systematic review, facial rejuvenation treatments and devices that focus on decreasing adverse effects and improving downtime were identified: lasers, light therapy, and non–laser-based thermal tightening.
Improved efficacy and safety with nonablative fractioned lasers and intense pulsed light has led to improved options with minimal downtime for patients with mild to moderate degree of photoaging; however, full-field resurfacing remains important for more severe photoaging and facial rhytids.
The market for nonsurgical, energy-based facial rejuvenation techniques has increased exponentially since lasers were first used for skin rejuvenation in 1983. Advances in this area have led to a wide range of products that require the modern facial plastic surgeon to have a large repertoire of knowledge.
To serve as a guide for current trends in the development of technology, applications, and outcomes of laser and laser-related technology over the past 5 years.
We performed a review of PubMed from January 1, 2011, to March 1, 2016, and focused on randomized clinical trials, meta-analyses, systematic reviews, and clinical practice guidelines including case control, case studies and case reports when necessary, and included 14 articles we deemed landmark articles before 2011.
Three broad categories of technology are leading non–energy-based rejuvenation technology: lasers, light therapy, and non–laser-based thermal tightening devices. Laser light therapy has continued to diversify with the use of ablative and nonablative resurfacing technologies, fractionated lasers, and their combined use. Light therapy has developed for use in combination with other technologies or stand alone. Finally, thermally based nonlaser skin-tightening devices, such as radiofrequency (RF) and intense focused ultrasonography (IFUS), are evolving technologies that have changed rapidly over the past 5 years.
Conclusions and Relevance
Improvements in safety and efficacy for energy-based treatment have expanded the patient base considering these therapies viable options. With a wide variety of options, the modern facial plastic surgeon can have a frank discussion with the patient regarding nonsurgical techniques that were never before available. Many of these patients can now derive benefit from treatments requiring significantly less downtime than before while the clinician can augment the treatment to maximize benefit to fit the patient’s time schedule.
The term laser originated from an acronym that stands for light amplification by stimulated emission of radiation. Its use is a cornerstone for today’s facial plastic surgeon (Figure 1). The landmark article by Anderson and Parrish1 in 1983 on selective photothermolysis began the era of laser-therapy skin rejuvenation. These techniques were expanded on by Manstein et al2 in the seminal article on fractional photothermolysis in 2004. This leap in laser technology reduced scarring by using microscopic treatment zones used to promote tissue remodeling and ushered in an era in minimal downtime after laser therapy. Over the past decade, laser technology, in addition to intense pulsed light (IPL), radiofrequency devices, and focused high-frequency ultrasonography technologies, has increased options for patients in facial rejuvenation, resurfacing, and tightening.
With the advent of such technologies, both supply and demand have increased at incredible speeds. According to the American Society for Plastic Surgery statistics, which provide a comprehensive estimate on the total number of cosmetic procedures performed in the United States, minimally invasive cosmetic procedures laser resurfacing procedures have increased by more than 200% since 2000. In 2014, more than 540 000 laser skin-resurfacing procedures were performed with a 6% increase from 2013, 87% of which were performed in women.3 These statistics do not include the large number of non–laser-based products used for facial rejuvenation and tightening or light-based facial rejuvenation technologies. With the ever-expanding repertoire of technology and products, it is important to understand the efficacy of each to match the demand.
We performed a review of PubMed from 2011 to 2016 using specific search strategies, modeled after systematic reviews but confined a 5-year constraint.4 Our primary search used the terms summarized in Table 1, and we also included 14 articles that we deemed landmark articles published before 2011. We restricted articles to human data reported in the English language. We screened articles published between January 1, 2011, and March 1, 2016, and focused on randomized clinical trials (RCTs), meta-analyses, systematic reviews, and clinical practice guidelines, including case-control studies, case studies, and case reports when necessary. These searches generated 692 articles, and all abstracts were reviewed. We selected articles for full review that were deemed to provide major advances in the diagnosis or treatment of laser and light treatment (Figure 2). Articles were excluded if there was only histologic analysis, clinical analysis was lacking, primary therapies were non–energy based or invasive, they were nonsystematic reviews, they contained technological evaluation unrelated to therapy, or the therapy was not applicable to facial rejuvenation. We considered sources of bias in these articles and defined areas of uncertainty as those in which the evidence conflicted.
Full-field ablative or traditional laser resurfacing removes the entire skin surface in the area being treated with depth of injury depending on energy level. Ablative skin resurfacing was popularized in the 1990s after the introduction of pulsed carbon dioxide systems. At that time, carbon dioxide laser was largely used for treatment of acne scarring and facial rhytids. This technique continues to be used to treat severe acne scarring and moderate rhytids with a high degree of patient satisfaction, as well as to treat prolonged erythema and pigmentation issues.5 The introduction of the erbium yttrium aluminum garnet (erbium:YAG) laser allows for minimal thermal damage and quicker postoperative healing with the tradeoff of decreased tissue tightening.6 Newer erbium:YAG lasers (Contour TRL) use a simultaneous combination of ablative and nonablative resurfacing for severe perioral rhytids to minimize recovery time while maximizing benefit of each individual treatment.7 Full-field resurfacing is great tool for improvement in patients with moderate photoaging and rhytids who are willing to undergo a longer downtime for the benefit of a single treatment. Clinical experience by the senior author (B.C.M.) and colleagues confirm that extensive facial resurfacing with a tunable erbium:YAG laser can be performed with dramatically reduced risks of hypopigmentation, scarring, or postinflammatory hyperpigmentation.
Fractional laser resurfacing treats a small “fraction” of the skin at each session, leaving skip areas between each exposed area. Fractional ablative resurfacing with carbon dioxide was initially described in 2007.8 Carbon dioxide fractionated resurfacing improves photodamage by approximately 50%, with downtime generally limited to 1 week and an improved adverse effect profile over full-field resurfacing.9,10 erbium:YAG, yttrium-scandium-gallium-garnet (YSGG) and Er:YSGG (2790-nm) systems were introduced with the intent of providing more significant results than nonablative fractional systems while achieving shorter healing times and complications when compared with full-field ablative systems.11 erbium:YAG lasers can be used in multiple sessions with increased fluence to increase improvement in photoaging without increasing down time while also increasing the amount of new collagen formation.12 One study showed a 26% to 75% improvement in photoaging with multiple passes and a higher fluence with only a 3- to 4-day downtime.13 The tradeoff of these lasers compared with full-field ablative lasers is the need for multiple sessions to achieve similar results.
The first nonablative fractional laser was the Fraxel device (Reliant Technologies Inc [now Solta, a subsidiary of Valeant Pharmaceuticals]).2 Similar to ablative lasers, these devices primarily target dermal water, which causes collagen heating and dermal remodeling. Unlike their ablative counterparts; however, epidermal injury and tissue vaporization do not occur owing to the concomitant application of epidermal cooling. Several different nonablative, fractional lasers are now used with promising results, with an improved safety profile.14 The long-pulsed Nd:YAG (LPND) has shown modest improvement in rhytids and photoaging with erythema resolving almost immediately after treatment.15 These lasers tend to have more modest results and are geared to mild-to-moderate photo damage and solar lentigines but allow for quick recovery with little risk.16,17 These lasers can also be used for resurfacing in darker skin types—a major advance in treating nonwhite patients
Newer techniques involve the use of fractionated lasers with both ablative and nonablative properties with reduced adverse effects compared with deeper, purely ablative lasers.18,19 The 2790 nm erbium:YSGG laser (Pearl; Cutera), an ablative laser with mild thermal coagulation showed significant improvement in patients with rhytids and fine lines to the 2-year mark without adverse effects and minimal downtime.20 The combined effects of ablative and nonablative fractional lasers allow for a higher degree of rejuvenation than the nonablative lasers while maintaining less downtime than full-field ablative fractional lasers. Multiple sessions are, however, still required.
The nonlaser, light systems used for nonablative rejuvenation are group of devices that emit wavelengths in the visible (400-760 nm), near-infrared (760-1400 nm), or mid-infrared (1.4-3 μm) ranges. Both IPL and light-emitting diodes (LEDs) are in this group. These modalities induce dermal remodeling without epidermal ablation. Most investigators believe that photothermal heating of the dermis both increases collagen production by fibroblasts and induces remodeling of the dermal matrix.
Intense pulsed light was first described for the treatment of rhytids and photodamaged skin in 2000.21,22 In a multicenter study in 2004, IPL showed significant improvement in patient’s evaluation of the elastosis score at the 6-month follow-up with minimal adverse events and no down time.23 Because of their safety profile and lack of down time, they are often used in combination with other lasers to enhance rejuvenation. Large series show that hyperpigmentation is possible, but only in a small proportion of patients (2.96%).24 Fractionated IPL and pulse in pulse IPL may mitigate some risk of hyperpigmentation from IPL and thus may be safer in patients with melasma.25,26
An erbium:YAG laser alone was compared with a combination erbium:YAG laser with IPL treatments and showed improvement in the Fitzpatrick wrinkle scale in both groups but a showed greater improvement in pigmentation in the combination group.27 In a split-face study looking at IPL and nonablative fractional laser treatment alone and in combination for photoaging, the treatment in combination proved statistically superior with no increase in adverse outcomes.28 Combination therapy of IPL and fractional erbium:YAG laser treatment compared with IPL alone in a split-face study showed global improvement in pigmentation, pore size, rhytids, and skin texture in all groups compared with base line with significant improvement in the combination therapy compared with IPL alone.29 These studies show that the IPL in combination with other laser techniques can improve skin clarity with a minimal adverse effect profile or additional down time.30
All nonsurgical skin-tightening devices work by delivering thermal energy to the skin or underlying structures. This creates immediate mechanical contraction of collagen fibers and delayed biochemical remodeling and neocollagenesis via the wound-healing response. New therapies available include radiofrequency (RF) and intense focused ultrasonography (IFUS) or microfocused ultrasonography (MFU). Nonsurgical skin tightening is best suited to patients with mild to moderate skin laxity and photoaging, or extrinsic aging, without significant underlying structural ptosis. Patients with underlying structural and excessive skin laxity with deep rhytids from intrinsic aging are likely to have limited improvement compared with surgical techniques and should be counseled appropriately.31
Ultrasonographic therapy (MFU or IFUS) works by creating precision microwounds in the dermis without affecting the epidermis with varied high-frequency ultrasound waves.32 It is very effective in thin patients with mild to moderate skin laxity with proven results both subjectively and objectively, and it is safe in all Fitzpatrick phototypes.33,34 In one study35 using computer-assisted measurements, 63.6% had improvement in their skin laxity; while only 12.2% of patients with body-mass index, calculated as weight in kilograms divided by height in meters squared, greater than 30 had improvement at 3 months. A study examining IFUS (Ulthera system, Ulthera Inc) for tightening infraorbital laxity with 1 to 2 treatments showed improvement in all patients at 6 months.36 In a similar study, 67% of patients undergoing 1 treatment of MFU had improvement in skin laxity at 6 months.37 Intense focused ultrasonography has significant promise as a nonsurgical therapy for skin and pore tightening,38 but long-term outcome data are still lacking.
Radiofrequency works by using the natural electrical resistance of the tissues to convert that energy into thermal energy. Both monopolar and bipolar forms of this technology are available. Results are again limited by follow-up, but have shown improvement compared with baseline. In one study31 comparing the RF device with traditional surgical face-lift, improvements were modest; however, patients had a high degree of satisfaction in both groups. In another study39 looking at bipolar radiofrequency tightening of the face and neck, 14 patients underwent a series of 4 to 6 weekly treatments, and their outcomes were measured by 3 blinded physicians. All patients reported experiencing improvement. Modest improvements in dyschromia and skin texture are also reported.40 Taub et al41 examined patients undergoing 6 monopolar treatments over six months and showed an average of 30% patient improvement at 1 year since the first treatment, the longest follow-up to date. Obviously, additional study with a more validated approach will be very helpful in evaluating this technology.
Ablative fractionated lasers are used to successfully treat acne scars, including severe scars on a variety of anatomic locations. Treatments are typically performed as a single procedure owing to their robust clinical results compared with nonablative fractional lasers.42,43 In a study by You et al,44 resurfacing carbon dioxide and erbium:YAG lasers were compared with fractional lasers, both ablative and nonablative, and results were measured by blinded investigators. They found that carbon dioxide lasers caused more hyperpigmentation and erythema, and that all results were comparable with the exception of less dramatic results in the nonablative group. They also found that that 3 ablative fractionated laser treatments were equivalent to the resurfacing lasers with shorter downtime periods and less adverse effects.44
Nonablative fractional lasers can be successfully used in the treatment of various forms of scarring, including acne scarring, with a very favorable safety profile. Alster et al45 showed impressive results with mild to moderate acne scarring; 87% of patients who received 3 treatments at 4-week intervals showed at moderate improvement in the appearance of their acne scars. Nonablative fractional lasers can also be safely used to treat acne scarring in darker-pigmented patients. A study of 22 Korean patients with skin types III or V who were treated with erbium:YAG nonablative fractional resurfacing treatment, with 1 patient experiencing mild hypopigmentation and 1 patient experiencing postinflammatory hyperpigmentation lasting longer than 3 months.46
Improvements in surgical and traumatic scarring are also abundant. Keaney et al47 looked at pulsed dye laser (PDL) vs potassium titanyl phosphate (KTP) laser for the treatment of erythematous surgical scars in a randomized study showing significant improvement in both groups and only more significant improvement in vascularity in the KTP arm without significant adverse effects. In a study48 looking at nonablative vs ablative fractional laser treatments for postthyroidectomy scars, no difference was seen between the 2 systems, but the nonablative system was better for lightening color and the ablative system was better at decreasing hardness arguing for a combined approach. Another study49 looked at the difference between PDL and carbon dioxide ablative fractional lasers and significant improvement in both groups, but there was no statistical difference between the 2 groups. The PDL group was superior in improvement of vascularity and pigmentation, and the ablative group was superior in pliability and thickness.
Several different laser and light therapies are available for the treatment of melasma. Intense pulsed light safety and efficacy was examined in a 10-week split-face study using a triple combination cream (Tri-luma Cream, Galderma Laboratories LP) vs placebo. Results were improved at 10 weeks vs placebo, but the active ingredient group had more skin irritation.50 A randomized open label study was performed for refractory melasma comparing IPL with bleaching agents and sunscreen alone vs in conjunction with IPL. There was significant improvement in the melasma group out to 1 year compared with the control group with only 1 session of IPL.51 Similarly, nonablative fractional lasers were compared with triple topical therapy (hydroquinone, 5%; tretinoin, 0.05%; and triamcinolone acetonide cream, 0.1%) with comparable efficacy, and the authors stated that laser treatment should be considered if topical bleaching is ineffective or cannot be tolerated.52
Fractionated lasers on decreased settings can be effective and safe with both ablative and nonablative techniques.53 Q-switched neodymium-doped yttrium aluminum Garnet (QS-Nd:YAG) laser vs hydroquinone for the treatment of melasma was compared in a randomized split-face study with improved patient satisfaction and lightening of the QS-Nd:YAG treated side; however, all patients had recurrence of their melasma at 12 weeks after treatment.54 Comparing QS-Nd:YAG with glycolic acid peels, improvement in the melasma area and severity index (MASI) score in the QS-Nd:YAG group was seen, and, when the treatments were combined, there was superior improvement objectively in the group using the modified MASI.55,56 QS-Nd:YAG and IPL combination therapy compared with QS-Nd:YAG alone and IPL alone showed an improvement over QS-Nd:YAG alone and IPL alone with combination therapy; however, recurrence was still an issue.57,58
Pulsed dye laser with triple-combination therapy was compared with triple-combination therapy alone in a split-face study showing improvement in the MASI on the combination side with statistically significant improvement at the 2-month follow-up visit; however, postinflammatory hyperpigmentation (PIH) did occur.59 Fractional laser therapy using both ablative and nonablative lasers were compared in several studies showing high recurrence rates with fractional therapy and a higher incidence in PIH.60,61 Melasma continues to be a difficult problem, with frequent recurrence, but refinements in techniques are helping identify the optimal treatment to improve pigmentation without hypopigmentation or worsening PIH.
Darker skin types, Fitzpatrick type V and VI, have thicker and more compact skin layers with thicker collagen bundles, which increase the epidermal barrier and reduce skin sensitivity in addition to a higher density of larger melanosomes.62- 64 Ablative nonfractionated lasers, including the carbon dioxide and the erbium:YAG, can lead to improvements in rhytids and acne scars in darker skin; however, these are contraindicated in Fitzpatrick type V and VI skin owing to the risk of dyspigmentation and scarring.64 These risks are somewhat mitigated in patients using nonablative nonfractionated lasers, such as the 1319-nm PDL, 1320-nm Nd:YAG, and the 1540-nm diode laser, with improvement in acne scars and overall scar severity, but they do not have the improvement in rhytids seen with patients treated with more aggressive lasers.62,63,65,66
Fractionated lasers improve safety profiles further. Nonablative fractionated lasers, such as the 1440-nm Nd:YAG, 1550-nm Er laser, and 1927-nm thulium fiber laser, can moderately improve skin texture, acne scarring and rhytids.62,64,65 Ablative fractionated lasers are perhaps the best balance for darker skin. These include the 10 600-nm fractional carbon dioxide laser, the 2940-nm erbium:YAG laser, and the 2700-nm Er:YSGG laser. They improve downtime over nonfractionated lasers and still have moderate power to resurface mild skin laxity and rhytids.62 There is still risk of dyspigmentation; however, and they should be used with caution in type VI skin.62 Finally, other energy-based therapies including RF and IFUS seem to be safe in darker skin.34,67
Advances in energy-based technology for facial rejuvenation over the past decade focus primarily on reducing the adverse effect profile and decreasing downtime while trying to achieve effective results (Table 2 and Table 3). Full-field ablative resurfacing continues to lead to superior results among energy-based therapies for patients with moderate photoaging; however, patients must be counselled about longer downtimes and higher risk of adverse effects.16 More modest improvements are seen in fractionated lasers, with shorter down time.11,13 Fractionated lasers show significant promise in scar remodeling for both acne and surgical scars and can be used safely with minimal downtime in most patients.43,44,46,48,49 Finally, newer techniques in ultrasonographic therapy and radiofrequency energy–based therapy have promise in improving skin laxity with less downtime, but studies are needed to characterize long-term benefit.33,35,36,39
With the advent of fractionated lasers and IPL therapy, improvements in mild photoaging are seen even in combination therapy with minimal risk for adverse effects and almost no downtime.27- 29 More treatments are generally required to achieve satisfactory results. This safety profile makes these lasers optimal for patients with melasma or with ethnic skin. Similar risks do remain with both hypopigmentation and hyperpigmentation, to a lesser degree, and the patient should be counselled appropriately.57- 59
This review has several limitations. First, we restricted our search to the past 5 years, with few exceptions. We tried to limit our search to reports of patients receiving only energy-based therapy, excluding many, but not all, articles that included other types of therapy. We recognize that the articles reviewed were extremely heterogeneous in their method and type of treatment. No uniform treatment exists for any particular problem examined, increasing the risk of bias in reviewing these studies. Finally, many studies do not possess a high level of evidence and those that do are underpowered. We recognize the difficulty in performing a high-power, randomized study in cosmetic literature.
This review carefully assesses the current energy-based facial rejuvenation techniques in the facial plastic surgeon’s armamentarium. Nonsurgical facial rejuvenation technology has rapidly expanded over the past 5 years. The focus of this technology is shifting to carefully balance minimal risks and downtime while maximizing outcomes. Patients should be informed about the benefits, adverse effects, duration of effect, and need for further treatments. An informed decision must be made between the facial plastic surgeon and their patients as to the appropriate treatment. Many of these technologies are new, and further study is required to further elucidate optimal treatments for all conditions regarding photoaging.
Corresponding Author: Christopher J. Britt, MD, Division of Otolaryngology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Room K4-721, Madison, WI 53705 (email@example.com).
Accepted for Publication: August 22, 2016.
Published Online: December 1, 2016. doi:10.1001/jamafacial.2016.1435
Author Contributions: Both authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Both authors.
Acquisition, analysis, or interpretation of data: Both authors.
Drafting of the manuscript: Britt.
Critical revision of the manuscript for important intellectual content: Both authors.
Statistical analysis: Britt.
Administrative, technical, or material support: Britt.
Study supervision: Marcus.
Conflict of Interest Disclosures: None reported.