Atlas Phẫu Thuật Thẩm Mỹ (Tập 2) – Atlas of Cosmetic Surgery

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Chapter 14
Cosmetic surgery procedures and techniques
needs to clarify the incremental benefit of this treatment to
more traditional photodynamic therapy treatments.
Long-wavelength noncoherent infrared light
Long-wavelength infrared broadband light devices have been
developed to tighten sagging or lax facial skin. However, these
devices also emit at mid-infrared wavelengths that may have
utility in improving skin surface abnormalities, including
texture and fine rhytides. A representative device, the Titan
(Cutera, Brisbane, CA), is a noncoherent infrared light that
emits energy at 1100–1800 nm. These wavelengths are absorbed
by water in the dermis and the mechanism of action is likely
similar to that caused by the coherent mid-infrared devices.
Few analytic in vivo studies have been published, but cadaveric
studies and skin tissue taken from the abdomen of one treated
patient suggest collagen fibril denaturation immediately after
treatment at areas 1–2 mm below the skin ­surface.50
To the extent that collagen remodeling also underlies
­reduction of fine lines and wrinkles, and plumping of the
skin leading to improved texture, those outcomes may also be
­expected.
Clinical studies with the 1100–1800 nm device have elu­
cidated the apparent tissue tightening observed, but have
been less descriptive about surface rejuvenation effects, such
as diminished redness, pigment, and fine textural abnormali­
ties.51,52 The notable edema and erythema that have been
reported may be proxies for such impending skin surface
­alteration.
Light emitting diodes
These light sources are marketed as GentleWaves, a 590 mm
device (Light BioScience, Virginia Beach, VA), LumiPhase-R at
660 nm (OpusMed Inc., Montreal, Canada), and Omnilux at
633 nm and 810 nm (Phototherapeutics, Orange County, CA).
Light emitting diodes (LEDs) emit narrow bands of poly­
chromatic, low-intensity light. The LEDs are often arranged
in panels to treat large areas for photorejuvenation. At a theo­
retic level, LED devices are said to emit ‘codes,’ or patterns
of signals, that may selectively up- or down-regulate intrami­
tochondrial processes within cells. This cellular modulation is
said to induce skin improvement and rejuvenation, but the pre­
cise mechanism has not been elucidated. Uncontrolled studies
have shown improvement in texture, periorbital rhytides, ery­
thema, and pigmentation in 93 patients treated over 4 weeks
with eight treatments.53 Controlled, prospective, randomized,
split-face trials have not been published. Recently, there has
been some increased skepticism within the scientific commu­
nity regarding the utility of LED devices for facial rejuvena­
tion.54 It remains unclear whether patient acceptance of these
devices is associated with measurable skin improvement or if
patients prefer this treatment because the gentle warming
­sensation is pleasant rather than painful.
LED devices are of significant use in combination with
topical 5-aminolevulinic acid or other topical photosensitiz­
ing agents. To the extent that blue or red light LEDs emit at
­wavelengths that are well suited to maximizing the efficacy
of photodynamic therapy, they can improve photodamage,
actinic damage, and color and texture irregularities. LEDs
can thus be used for rejuvenation, although the primary effect
may well be from the photosensitizing agent, with the light
emitting ­ diode functioning as a efficient and relatively less
painful means for activating the topical solution.
Therapeutic ultrasound
Ultrasound, a long-known diagnostic modality, has clinical
application for skin rejuvenation. During the last few years,
several companies have developed means for skin tightening
using ultrasound, with the primary attraction of ultrasound
being its ability to deliver high energies very deep into the
skin and subcutis without injuring surface skin structures.
Unpublished data indicate that some such therapeutic ultra­
sound devices (Ulthera Inc., Phoenix, AZ) are of utility for
traditional nonablative rejuvenation, including reduction of
periorbital fine lines and static fine forehead lines.
• With regard to noncoherent light sources, IPL
can simultaneously treat superficial vascular and
pigmented lesions.
• Newer IPL devices can provide more specific
intended effects with reduced adverse events.
• The newest IPL devices with emissions in the
infrared range are of modest efficacy in treating
rhytides while mostly addressing tightening.
• Similarly, combined radiofrequency and light/
laser devices are intended mostly for skin
­tightening, but may have some rejuvenation
effects, including wrinkle reduction and skin
texture improvement.
• LEDs are comfortable and pleasing, and
are well tolerated by patients who find other
­rejuvenating light treatments to be too painful;
LEDs can also be used in combination with topi­
cal ­photosensitizers to improve skin color and
­texture.
• Therapeutic ultrasound may have some efficacy
in treating fine static lines of the face.
Pearls
• IPL systems can cause similar adverse events as
laser modalities.
• Earlier IPL devices enabled users to set many
more treatment parameters, thus increasing the
risk for hyperpigmentation or epidermal ­damage.
• IPL devices may induce persistent
­hypopigmentation if used incorrectly, but this
can be avoided by modifying or reducing
­fluence.
• The promising theory underlying the potential
benefits of LED devices is not yet verified by
­efficacy data from controlled studies.
Pitfalls

207
Nonablative rejuvenation  •  Chapter 14
Postoperative clinical ­considerations
Although most nonablative techniques have fewer risks than
ablative techniques, the postoperative concerns of the patients
must still be addressed. Patients should be reassured that these
techniques can cause transient erythema and edema, but that
such minor effects resolve within 24–48 hours. Managing
patient expectations is the most important factor in postopera­
tive care of patients who have had nonablative rejuvenation.
In this vein, the most important element of expectation
management is preoperatively discussing, and postoperatively
reminding, patients of the limited benefits of nonablative reju­
venation. Patients should be told that multiple treatments are
usually required and that results range from the very subtle
to the more obvious, but that slow, incremental improvement
rather than dramatic change is the norm. Patients should
also understand that significant intraoperative pain can occur
­during some of these treatments, and that they may not feel
their best for the first day or two thereafter. On a more opti­
mistic note, patients should be reassured of the very high
degree of safety of such treatments, and the vanishingly low
risk of permanent scarring or pigmentary change.
Post-treatment, and between nonablative treatments, the
physician should assess the response to date and determine
how to proceed. If results are minimal and the patient is tol­
erating treatments well, higher fluences or more passes may
be indicated at subsequent sessions. Conversely, in darker-
skinned patients who develop transient hyperpigmentation,
or in patients who note that they had a prolonged recovery
time after the last procedure, waiting a few more weeks before
retreating or retreating at lower fluence may be appropriate.
It is also appropriate to ask patients about their subjective
assessment of the efficacy of previous treatments. Traditional
nonablative treatments gradually address dyspigmentation,
including erythema, telangiectasia, and lentigines, and fine
perioral and periorbital rhytides, and subtle textural irregu­
larities; however, it is possible that patients may have an unar­
ticulated desire for some other type of skin improvement. For
instance, if patients express disappointment that they have
had inadequate tightening of the jowls, or if the degree of
perioral rhytide reduction is perceived as insufficient, they may
be ­better served by different types of treatment in the future.
Tightening may be achieved by radiofrequency or ­ultrasound
tightening devices, and greater wrinkle reduction by fractional,
partially ablative resurfacing or traditional ablative resurfacing
techniques. Selective use of fillers or botulinum toxin may also
be appropriate to fill depressed areas of the lower face, cheeks
or glabella, or to smooth dynamic ­creases. ­Indeed, if patients
express deep disappointment with prior nonablative rejuvena­
tion treatments, it may be worth considering if they would
prefer treatment of coarser rhytides and sagging with higher
risk, non-minimally invasive technologies, such as rhytidec­
tomy or blepharoplasty. Even the most competent application
of a given skin improving treatment, such as nonablative reju­
venation, will not assure patient satisfaction if the outcomes
are not consonant with patient expectations. In general, it is
better to frequently reassess patient ­expectations, even at the
expense of changing course midtreatment, than to risk even­
tual long-term patient dissatisfaction upon completion of a
treatment course that does not meet expectations.
Future directions
The demand for nonablative rejuvenation is increasing as
current devices are refined and patients become accustomed
to growing efficacy with diminishing down-time. When the
molecular mechanisms underlying nonablative therapy are
better understood, improved devices may be feasible that
provide more specific improvements with fewer treatments.
­Ideally, such next-generation devices would selectively address
different types of age-associated skin damage, and be optimiz­
able for individual patients. In the distant future, advances in
nanotechnology may facilitate even more precisely directed
interventions.
At no point should traditional nonablative rejuvenation be
considered as a solitary treatment that must stand alone. Like
all minimally invasive rejuvenation modalities, it must be incor­
porated into a complete patient treatment plan that ­addresses
the desires and needs of the patient, not the ­limitations of
technology. Combination rejuvenation ­ approaches, using
the above-described nonablative therapies with other energy
­devices, chemical peels, soft tissue augmentation, botulinum
toxin, and the like, will usually be the best means to improve
patients’ skin texture, pigmentation, and contour with ­minimal
morbidity.
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Chapter 14
Cosmetic surgery procedures and techniques
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20. Tanzi EL, Williams CM, Alster TS. Treatment of facial rhytides with
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22. Paithankar DY, et al. Acne treatment with a 1,450 nm wavelength laser
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25. Fournier N, Mordon S. Nonablative remodeling with a 1,540 nm
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26. Fournier N, Lagarde JM, et al. A 35-month profilometric and clinical
evaluation. J Cosmet Laser Ther 2004; 6(3):126–130.
27. Fournier N, et al. Nonablative remodeling: a 14-month clinical
ultrasound imaging and profilometric evaluation of a 1540 nm Er:glass
laser. Dermatol Surg 2002; 28(10):926–931.
28. Dahan S, et al. Treatment of neck lines and forehead rhytides with a
nonablative 1540-nm Er:glass laser: a controlled clinical study combined
with the measurement of the thickness and the mechanical properties of
the skin. Dermatol Surg, 2004; 30(6):872–879; discussion 879–880.
29. Lupton JR, Williams CM, Alster TS. Nonablative laser skin resurfacing
using a 1540 nm erbium glass laser: a clinical and histologic analysis.
Dermatol Surg 2002; 28(9):833–835.
30. Allen RG, et al. Ocular effects of pulsed Nd laser radiation: variation of
threshold with pulsewidth. Health Phys 1985; 49(5):685–692.
31. Ham WT Jr., et al. Action spectrum for retinal injury from near-
ultraviolet radiation in the aphakic monkey. Am J Ophthalmol 1982;
93(3):299–306.
32. Kono T, et al. Treatment of hypertrophic scars using a long-pulsed dye
laser with cryogen-spray cooling. Ann Plast Surg 2005; 54(5):487–493.
33. Rostan E, et al. A double-blind, side-by-side comparison study of low
fluence long pulse dye laser to coolant treatment for wrinkling of the
cheeks. J Cosmet Laser Ther 2001; 3(3):129–136.
34. Zelickson BD, et al. Pulsed dye laser therapy for sun damaged skin.
Lasers Surg Med 1999; 25(3):229–236.
35. Goldberg DJ, et al. Clinical, histologic, and ultrastructural changes after
nonablative treatment with a 595-nm flashlamp-pumped pulsed dye
laser: comparison of varying settings. Dermatol Surg 2004; 30(7):
979–982.
36. Reynolds N, et al. Pulsed dye laser and non-ablative wrinkle reduction.
Lasers Surg Med 2004; 34(2):109–113.
37. Tan MH, et al. Clinical evaluation of enhanced nonablative skin
rejuvenation using a combination of a 532 and a 1,064 nm laser. Lasers
Surg Med 2004; 34(5):439–445.
38. Lee MW. Combination 532-nm and 1064-nm lasers for noninvasive
skin rejuvenation and toning. Arch Dermatol 2003; 139(10):1265–1276.
39. Fitzpatrick TB. The validity and practicality of sun-reactive skin types I
through VI. Arch Dermatol 1988; 124(6):869–871.
40. Hedelund L, et al. Skin rejuvenation using intense pulsed light: a
randomized controlled split-face trial with blinded response evaluation.
Arch Dermatol 2006; 142(8):985–990.
41. Bitter P Jr, Mulholland S. Report of a new technique for enhanced
non-invasive skin rejuvenation using a dual mode pulsed light and radio-
frequency energy source: selective radiothermolysis. J Cosmet Dermatol
2002; 1:142–143.
42. Sadick NS, et al. Enhanced full-face skin rejuvenation using synchronous
intense pulsed optical and conducted bipolar radiofrequency energy
(ELOS): introducing selective radiophotothermolysis. J Drugs Dermatol
2005; 4(2):181–186.
43. Doshi SN, Alster TS. Combination radiofrequency and diode laser for
treatment of facial rhytides and skin laxity. J Cosmet Laser Ther 2005;
7(1):11–15.
44. Kulick M. Evaluation of a combined laser–radiofrequency device
(Polaris WR) for the nonablative treatment of facial wrinkles. J Cosmet
Laser Ther 2005; 7:87–92.
45. Hammes S, Greve B, Raulin C. Electro-optical synergy (ELOS)
technology for nonablative skin rejuvenation: a preliminary, prospective
study. J Eur Acad Dermatol Venereol 2006; 20:1070–1075.
46. Sadick NS, Trelles MA. Nonablative wrinkle treatment of the face and
neck using a combined diode laser and radiofrequency technology.
Dermatol Surg 2005; 31(12):1695–1699.
47. Alexiades-Armenakas M. Rhytides, laxity, and photoaging treated with a
combination of radiofrequency, diode laser, and pulsed light and assessed
with a comprehensive grading scale. J Drugs Dermatol 2006; 5:609–616.
48. Dingley M. A randomized, comparative study to determine the efficacy
of the intense pulsed light alone vs. the intense pulsed light combined
with bipolar RF for skin rejuvenation. American Society for Laser
Surgery and Medicine, Annual Meeting, 2007, abstract.
49. Hall JA, Keller PJ, Keller GS. Dose response of combination
photorejuvenation using intense pulsed light-activated photodynamic
therapy and radiofrequency energy. Arch Facial Plast Surg, 2004;
6(6):374–378.
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forehead and abdominal skin. Dermatol Surg 2006; 32(7):
897–901.
51. Ruiz-Esparza J. Near painless, nonablative, immediate skin contraction
induced by low-fluence irradiation with new infrared device: a report of
25 patients. Dermatol Surg 2006; 32:601–610.
52. Taub AF, Battle EF Jr, Nikolaidis G. Multicenter clinical perspective on
a broadband infrared light device for skin tightening. J Drugs Dermatol
2006; 5:771–778.
53. Weiss RA, et al. Clinical trial of a novel non-thermal LED array for
reversal of photoaging: clinical, histologic, and surface profilometric
results. Lasers Surg Med 2005; 36(2):85–91.
54. Boulos PR. et al. In the eye of the beholder – skin rejuvenation with
gentlewaves LED photomodulation device. Dermol Surg 2007;
In press.

History and Science
History
Facial rejuvenation has become an increasingly popular
­practice as a result of the aging ‘baby boomer’ population
and a greater societal acceptance of cosmetic procedures. Al­
though dramatic clinical improvement of skin laxity can be
achieved with surgical lifting procedures, there is ­considerable
Nonsurgical Tissue
­Tightening
Elizabeth L. Tanzi and
Tina S. Alster
C h a p t e r
15
Key Points
n Nonsurgical tissue tightening is a good alternative
for patients who desire modest improvement of skin
laxity without the significant post-treatment recovery
associated with invasive surgical procedures.
n Good candidates for noninvasive tissue tightening
treatments are patients with mild-to-moderate skin
laxity and realistic clinical expectations.
n To date, nonsurgical tissue tightening has been
successfully accomplished with a monopolar
­radiofrequency device, combination bipolar
­radiofrequency and diode laser system, broadband
infrared light source, and 1064 nm Nd:YAG laser.
n Clinical efficacy of these devices has improved, with
fewer reported side effects since the acceptance of
advanced treatment algorithms.
n With ongoing advancements in technology and
techniques, further improvement of outcomes with
minimal postoperative recovery will be realized.
­associated postoperative recovery and monetary expense.
Therefore, noninvasive procedures with minimal postopera­
tive recovery and associated side effects are in high demand.
To meet the demands of patients who desire a more
­youthful appearance, many devices and techniques have
been ­ developed. Although ablative laser skin resurfacing is
a well-accepted treatment for facial rejuvenation because
of its ­ ability to predictably improve photodamaged facial
skin, patients may be hesitant to pursue this option because
of the extended postoperative recovery period and inher­
ent risks of the procedure.1–3 Because of the disadvantages
associated with ablative laser skin resurfacing procedures,
nonablative laser and light sources such as the 1320 nm Nd:
YAG, 1450 nm diode, and an intense pulsed light source were
developed. These nonablative lasers and light sources have
been researched, tested, and proven to provide dermal neo­
collagenesis without epidermal disruption.4–6 Disadvantages
of nonablative laser and light-based treatment include the
necessity for multiple treatments, delayed clinical effect, and
diminished results compared to those typically observed after
ablative laser skin resurfacing. Due to the limitations of these
ablative and nonablative ­ techniques, the development of a
truly noninvasive, deep ­tissue-tightening procedure continues
to be of great interest.
Radiofrequency (RF) tissue tightening was developed to
create deep thermal effects in the dermis, without external
cutaneous wounding. Early RF technologies involved low-
­energy modifications of traditional ablative RF electrosurgery
units that were used with limited success for tightening of the
skin due to the electric current being confined to a concen­
trated, shallow region around the perimeter of the electrode.
In 2002, a novel, monopolar RF device was developed to
­remodel and tighten collagen in the deeper dermis and sub­
cutaneous tissue in order to improve lax or aging skin. Unlike
traditional laser systems that generate heat by targeting specific
chromophores, RF technology generates heat as a result of
tissue impedance and is dependent on the electrical properties
p a r t 2

210
Chapter 15
Cosmetic surgery procedures and techniques
of tissue. The ThermaCool TC (Thermage, Hayward, CA)
device uses a novel form of monopolar RF energy to create a
uniform field of dermal and subdermal heating, while a con­
tact cooling device protects the epidermis. This RF system can
safely deliver higher fluences to a greater tissue volume than
can nonablative lasers. After receiving FDA clearance in 2002
for the reduction of periorbital rhytides, it has subsequently
been used for tissue tightening of the cheeks, mandible, and
upper neck,7–15 as well as for nonfacial skin tightening and
dermatochalasis.
Other devices have also been introduced in recent years to
address the issue of nonsurgical skin tightening including Pola­
ris WR (Syneron Medical Ltd., Israel), which combines bipo­
lar RF and diode laser energies (termed electro-optical synergy
or ELOS), Titan (Cutera, Brisbane, CA) which is a nonco­
herent, selectively filtered, broadband infrared light ­ device
that emits in multisecond cycles, and GentleYag (Candela
Corp., Wayland, MA) a long-pulsed, 1064 nm neodymium:
yttrium:aluminum:garnet (Nd:YAG) laser.
Science
Mechanism of action: monopolar
­radiofrequency
The ThermaCool TC monopolar RF device has four key
components: a radiofrequency generator, a handpiece, a cool­
ing module, and disposable treatment tips. Radiofrequency
energy production follows the principle of Ohm’s law, which
states that the impedance Z (ohms) to the movement of elec­
trons creates heat relative to the amount of current I (amps)
and time t (seconds).
Ohm’s Law
Energy (joules) = I 2 × Z × t
I = current (amps); Z = impedance (ohms); t = time (seconds)
The RF generator supplies a 6 MHz alternating current
across a specially modified monopolar electrode to deliver
volumetric heat to tissue. A disposable return pad connected
to the patient’s flank creates a path of travel for the radio­
frequency signal. The generator is regulated by a Pentium™
chip-based internal computer that processes feedback, includ­
ing temperature of the tip interface with the skin, ­application
force, amount of tissue surface area contact, and real-time
impedance of the skin. This information is gathered by a
­microprocessor in the handpiece and relayed to the generator
via a high-speed fiberoptic link (Fig. 15-1).
A unique capacitive coupling electrode disperses energy
uniformly across the very thin (1/1000 of an inch) dielectric
material on the treatment tip, thereby creating a uniform elec­
tric field (Fig. 15-2). The RF generator operates at 6 MHz,
which changes the polarity of an electrical field in biological
tissue six million times per second. The charged particles of
the tissue within the electric field change orientation at that
same frequency, and the dermal tissue’s natural resistance
(expressed in Ohm’s law as Z  ) to the movement of electrons
generates heat. The friction from electron movement cre­
ates volumetrically distributed deep dermal heating. Before,
during, and after delivery of the RF energy, a cryogen spray
Fig. 15-1  The Thermage ThermaCool™ device.
Fig. 15-2  The monopolar radiofrequency capacitively coupled
electrode treatment tip.

211
Nonsurgical tissue tightening  •  Chapter 15
­delivered onto the inner surface of the treatment tip mem­
brane provides cooling to protect the dermis from overheating
and subsequent damage. The treatment tip continually moni­
tors heat transmission from the skin via thermisters mounted
on the inside of the dielectric membrane. The cryogen spray
also provides cooling of the upper portion of the dermis. This
­creates a reverse thermal gradient through the dermis and re­
sults in volumetric heating and tightening of deep dermal and
even subdermal tissues (Fig. 15-3). The depth of this ­heating
is dependent on the treatment tip geometry and the dura­
tion of cooling. Tip sizes currently available include 0.25 cm,
1 cm, 1.5 cm, and 3 cm; however, additional sizes which may
potentially provide faster delivery of energy are under investi­
gation. New designs will permit further treatment parameter
variations, deeper tissue heating, and additional epidermal
­protection.
Each treatment cycle consists of three phases: precooling,
intratreatment cooling, and postcooling. To protect against
epidermal burning, the handpiece microprocessor aborts de­
livery of energy when all four tip corners are not in complete
contact with the skin.
The initial feasibility study of this RF device coupled
with a concurrent epidermal cooling system utilized a three-
­dimensional Monte Carlo simulation mathematical model to
gauge the theoretical temperature distribution in human skin.
The results showed that this unique tip design produced deep
dermal volumetric heating yet protected the superficial skin
from thermal injury, creating a much greater temperature rise
in the dermis than in the epidermis.16,17 The depth of the RF
field in tissue varies with the surface area of the treatment
tip electrode design. The larger the tip electrode surface area,
the deeper the heat produced. The amount of heat generated
depends on the impedance of the tissue being treated with
each pulse and on the selected treatment setting. The depth
of the protected tissue zone at the surface is controlled by the
cooling time and intensity. Therefore, the degree and depth
of heat generated in the tissue can be customized by changing
the size and geometry of the tip electrode, the amount of en­
ergy delivered (which directly correlates to tissue impedance),
and the cooling parameters designated for a given energy
­setting. These heating, cooling, and energy parameters are
programmed into a small eprom chip located within each dis­
posable treatment tip, with manufacturer-­optimized param­
eters automatically upgraded without active user intervention
or generator software upgrade.
In vivo studies show monopolar volumetric RF tissue heat­
ing creates a dual effect on collagen.7,17,18 Primary changes
to collagen occur as heat disrupts hydrogen bonds, altering
the molecular structure of the triple-helix collagen molecule
and resulting in collagen contraction. Secondary to the
­immediate thermal contraction of collagen, a more gradual
contraction due to wound healing is predicted to occur over
time as collagen regenerates, leading to a thicker ­remodeled
dermis. The secondary collagen synthesis in ­ response to
­thermal injury typically occurs 2–6 months after the pro­
cedure. Histologic examination of tissue specimens taken
4 months after treatment demonstrates epidermal and pap­
illary dermal thickening as well as shrinkage of sebaceous
glands (Fig. 15-4).
Mechanism of action: combination bipolar
radiofrequency and diode laser
The Polaris WR device is a combination 900 nm diode laser
and bipolar RF device. In contrast to monopolar RF, a bipolar
RF device conducts electric current between two electrodes
placed at a fixed distance on the skin (Fig. 15-5). Both elec­
trodes are applied to the target area, and the electrical cur­
rent propagation is limited by the area between the electrodes.
The main advantage of a bipolar system is the controlled
distribution of RF current inside the tissue, which is limited
by the volume between the two electrodes. The Polaris WR
device delivers RF energy ranging 10–100 J/cm2 and optical
energy ranging 10–50 J/cm2 in a sequential manner through
a unique 8 × 12 mm bipolar electrode tip with a pulse dura­
tion up to 250 ms (Fig. 15-6). Thermoelectric cooling at 5°C
provides epidermal protection throughout the pulse sequence.
The specific geometry of the bipolar electrodes permits heat­
ing to a maximal dermal depth of 2 mm. Furthermore, the
bipolar electrodes create controlled thermal injury to the deep
dermis at minimal individual optical and RF energies, thereby
limiting adverse effects of tissue overheating.
Similar to other devices that deliver controlled thermal
injury at the level of the dermis, the bipolar RF and diode
laser system effects a conformational change in the struc­
ture and length of collagen and may also induce a fibroblast
­response for long-term collagen remodeling. An increased
volume of collagen with more organization of fibers in the
dermis 6 months after a series of three consecutive Polaris
WR ­treatments has been reported.19
0º + 45 = 45º
10º + 45 = 55º
20º + 45 = 65º
30º + 45 = 75º
Fig. 15-3  Reverse thermal gradient created via simultaneous
cooling of the epidermis and heating of the dermis during mono­
polar radiofrequency treatment.

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Chapter 15
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Mechanism of action: broadband infrared
light source
Infrared light has also been used as a source of energy for
the purpose of noninvasive skin tightening.20,21 The Titan
system is a noncoherent, broadband, selectively filtered, in­
frared device that emits infrared light in multisecond cycles
(treatment cycle, 4–11 seconds) to target tissue water. A tai­
lored spectrum from 1100 nm to 1800 nm is delivered, with
filtering of the most strongly absorbed wavelengths in the
1400–1500 nm range (Fig. 15-7). The specifics of the system
effect tissue penetration to a depth of 1–2 mm, ideal for tar­
geting the reticular dermis. A multisecond exposure is deliv­
ered with sufficient energy to create the desired combination
of time and temperature for collagen contraction based on
the Arrhenius’ rate equation which describes the dependence
of a chemical reaction on temperature, time, and activation
energy. The epidermis is protected throughout the cycle by
concomitant contact cooling via a temperature-regulated
­sapphire crystal window.
Ultrastructural analysis using electron microscopy tech­
niques of forehead and abdominal skin treated with the Titan
device demonstrate immediate morphologic alterations of
collagen fibrils. Transmission electron microscopy has dem­
onstrated peak collagen fibril alteration at 1–2 mm in both ca­
daver and in vivo abdominal skin immediately after treatment
with the Titan infrared device.22 Histologic assessment of the
long-term effects of this infrared device on dermal collagen
are pending.
Mechanism of action: 1064 nm nd:yag laser
A long-pulsed 1064 nm Nd:YAG laser has also been used for
nonsurgical treatment of facial skin laxity.23–25 While mela­
nin, hemoglobin, and water are the targeted chromophores of
the 1064 nm Nd:YAG laser, weak absorption of the 1064 nm
A
B
Fig. 15-4  Human skin (A) before and (B) 4 months after treatment with the ThermaCool TC, showing epidermal thickening as well as
­increased dermal density.

213
Nonsurgical tissue tightening  •  Chapter 15
wavelength by melanin and hemoglobin is balanced by a
greater depth of penetration, thereby allowing delivery of the
near-infrared wavelength to the level of the dermis. Nonselec­
tive thermal injury upon 1064 nm laser irradiation has been
hypothesized to result in activation of dermal fibroblasts and
induction of a healing response.23,24 An additional benefit of
this wavelength is that patients with any skin phototype can be
treated with less risk of post-treatment dyschromia.
The GentleYAG laser delivers energy up to 50 J/cm2
through a 10 mm spot size. A 50 ms pulse duration with a rep­
etition rate of 2 Hz is most often used during treatment. The
epidermis is protected throughout the treatment cycle by a
cryogen dynamic cooling device.
Studies
Monopolar radiofrequency
To obtain FDA clearance for the aesthetic application of
monopolar RF, researchers undertook a 6-month study to
evaluate the device’s efficacy and safety.7 Eighty-six subjects
received a single treatment with the ThermaCool TC on
the forehead and temple area. On average, 68 cm2 of tissue
were treated with a single pass at energy settings ranging
65–95 J/cm2. Independent, blinded scoring of photographs
taken 6 months after treatment resulted in Fitzpatrick wrin­
kle score improvement of at least 1 point in 83.2% (99/119)
of treated periorbital areas. Additionally, 14.3% (17/119) of
treated areas demonstrated no change, and 2.5% (3/119)
worsened. Photographic analysis revealed an eyebrow lift of
at least 0.5 mm in 61.5% (40/65) of patients after 6 months.
Fifty percent (41/82) of subjects were satisfied or very satis­
fied with their treatment outcome. Incidence of side effects
was low and consisted of edema (13.9%) and erythema (36%)
immediately after treatment. By 1 month, no subject had
signs of edema, and only three (3.9%) had lingering signs of
erythema. Rare second degree burns occurred in 21 firings
of 5858 radiofrequency exposures, indicating a burn risk of
0.36% per application. Three patients had small areas of
­residual scarring 6 months after treatment. The authors con­
cluded that a single treatment with the monopolar RF device
reduced periorbital wrinkles, produced lasting brow elevation,
and improved eyelid aesthetics.
Hsu and Kaminer12 evaluated 16 patients treated with a
single pass on the cheeks, jawline, and/or upper neck. Treat­
ment levels averaged 113.8 J/cm2 on the cheeks, decreasing
to 99.7 J/cm2 on the neck. Although only one-third of the
patients reported satisfactory results, an interesting trend was
noted. Younger patients demonstrated greater improvement;
the average age of the unsatisfactory group was 58 compared
Electrode
Skin
Electrodes
Skin
A
B
Fig. 15-5  Schematic representation of the flow of electrical current
through the epidermis using (A) monopolar radiofrequency and
(B) bipolar radiofrequency treatment.
Fig. 15-6  Combination bipolar radiofrequency and diode laser
(Polaris WR) treatment tip.

214
Chapter 15
Cosmetic surgery procedures and techniques
with 51 in the group with an improved clinical outcome. The
authors attributed this finding to the fact that heat-labile col­
lagen bonds are progressively replaced by irreducible multi­
valent cross-links as the skin ages, thus rendering older skin
less amenable to heat-induced tissue tightening.
Ruiz-Esparza and Gomez10 reported clinically evident skin
tightening in 14 of 15 patients treated with a single mono­
polar radiofrequency treatment on the lower third of the face.
The authors noted that the nasolabial and mesolabial folds
were more responsive to treatment than the mandibular ridge
and jowls.
Alster and Tanzi8 evaluated cheek laxity in 30 patients and
neck laxity in 20 patients after one treatment with the mono­
polar RF device. The cheek treatment area extended laterally
from the nasolabial folds to the preauricular margin and inferi­
orly to the mandibular ridge. Treatment of the neck extended
laterally from the mandibular ridge to the mid-neck. Fluences
ranged 97–144 J/cm2 on the cheeks and 74–134 J/cm2 on the
neck. Mild post-treatment erythema was seen in all patients
and persisted up to 12 hours after the ­ procedure. Fifty-six
­percent of subjects complained of soreness at the treated sites;
which dissipated with oral nonsteroidal ­ antiinflammatory
medications. Erythematous papules that spontaneously
resolved over 24 hours were observed in three patients. One
patient developed dysesthesia along the mandible that re­
solved over 5 days. No blistering or scarring was observed.
A quartile grading system was used and independent masked
assessments noted improvement in 28 of 30 ­patients who were
treated on the cheeks and in 17 of 20 patients who received
treatment on the neck. The five subjects who demonstrated no
clinical improvement were all older than 62 years of age. At 6
months after treatment, the mean clinical ­improvement score
was 1.53 on the cheeks and 1.27 on the neck (scale: 1=25–50%
improvement; 2=51–75% improvement).
In an evaluation of 36 patients with photodamage or
rhytides, Iyer at al.9 showed that approximately 70% of
­patients noticed significant improvement in skin laxity
3 months after a single radiofrequency treatment with greater
improvement noted after multiple treatments. The patient
sample size receiving multiple treatments, however, was too
small (n=12) to draw definitive conclusions.
Nahm and colleagues15 demonstrated an average brow
elevation of 2–4 mm, superior palpebral crease elevation of
1.9 mm, and 22% jowl surface area improvement in a split-
face comparison after single-pass monopolar RF treat­
ment of the forehead. This study objectively confirmed that
­monopolar RF could improve eyebrow, eyelid, and jowl skin
laxity. Other investigators have also demonstrated satisfac­
tory skin ­tightening after a single, high-energy monopolar RF
­treatment.11,26
All of these aforementioned clinical studies evaluated the
original monopolar RF protocol using high energies delivered
in a single, nonoverlapping pass; however, based on clinical and
histological findings in 2004, a new treatment algorithm was
developed.18,27 Several investigators reported greater clinical
improvement with fewer side effects when a low-­energy, mul­
tipass technique was employed (Fig. 15-8).27–31 Weiss et al.30
retrospectively reviewed charts and clinical images of 600
consecutive treatments over a 4-year period. Treatment
was delivered with a 1 cm standard tip at fluences ranging
81–124 J/cm2 (level 12.5–15), a 1 cm fast tip at fluences rang­
ing 62–109 J/cm2 (level 72.0–76.0), a 1.5 cm fast tip at flu­
ences ranging 75–130 J/cm2 (level of 61.5–65.0), or a 3 cm
fast tip at equivalent fluences. Weiss et al. found that as treat­
ment algorithms evolved over 4 years, multiple passes at lower
fluence were associated with improved clinical outcomes
and greater patient acceptance. Other investigators14 evalu­
ated 25 patients after one monopolar RF treatment (fluences
62–91 J/cm2) using a multipass vector technique consisting
of four to five passes targeting prominent facial laxity. Pho­
tographic analysis of pre- and post-treatment digital images
demonstrated cosmetic improvement in facial and neck laxity
400 600 800 1000 1200 1400 1600 1800 2000 2200 2400 2600 2800 3000
1000
100
10
1
0
Absorption coefficient (cm–1)
Wavelength (nm)
Infrared
Water absorption
Titan broadband infrared spectrum
Fig. 15-7  Schematic representation of the tailored spectrum delivered by the infrared broadband light device (Titan). Wavelengths in the range
of 1100–1800 nm provide a penetration depth of up to 2 mm since the most strongly absorbed wavelengths in the range of 1400–1500 nm are
attenuated.

215
Nonsurgical tissue tightening  •  Chapter 15
in the majority of patients. No scarring or dyspigmentation
was noted in any study subject.
Combination bipolar radiofrequency
and diode laser
Doshi and Alster32 treated 20 patients with mild to moderate
rhytides and skin laxity with three consecutive treatments at
3-week intervals using the combined radiofrequency and diode
laser system (Polaris WR). Clinical improvement was deter­
mined using masked assessments by the treating investigator
and two independent assessors after each treatment session,
and at 3 and 6 months after the final treatment using a quartile
grading scale. Patient satisfaction surveys were also obtained at
end of study. Modest improvement in facial rhytides was ob­
served in the majority of patients as evidenced by investigator
and independent assessor evaluations. Patient satisfaction sur­
veys reflected the clinical improvements observed. Side effects
were mild and limited to transient erythema and edema.
Others19 evaluated 23 patients with grade II or III Glogau
wrinkling after three treatments with the Polaris WR (diode
laser ranging 30–50 J/cm2; bipolar radiofrequency ranging
80–100 J/cm2) delivered at 3-week intervals. More than 50%
of patients exhibited greater than 50% improvement in the
appearance of wrinkles, and the majority of study subjects
reported a noticeable improvement in skin smoothness and
texture.
Kulick33 evaluated the Polaris WR device for the nonab­
lative treatment of facial wrinkles in a small pilot study. Fif­
teen patients received three full-face treatments with energy
settings based on the severity of wrinkling (bipolar RF rang­
ing 50–100 J/cm2; diode laser fluence 15 J/cm2). Results ob­
served 4 weeks after the final treatment in eight patients (the
other seven patients dropped out before study completion)
demonstrated an average 25% reduction in skin wrinkling
(range 14–32%) based on evaluation of standardized clinical
­photographs.
A
C
B
Fig. 15-8  Multiple-pass monopolar radiofrequency treatment algorithm. (A) Three passes delivered to the treatment area in yellow, five passes
delivered to the treatment area in orange, and seven total passes to areas in red. (B) Pretreatment and (C) 7 months after a single monopolar
RF treatment (ThermaCool TC).

216
Chapter 15
Cosmetic surgery procedures and techniques
Broadband infrared light source
Ruiz-Esparza20 reported the findings of 25 patients treated with
the Titan broadband infrared device (fluences 20–40 J/cm2)
for eyebrow lifting, lower face tightening, or neck skin laxity.
Immediate skin contraction was obtained in 22 of 25 patients.
The initial improvement of eyebrow lifting or skin laxity was
maintained up to 12 months after treatment.
Others34 have also shown satisfactory results in a multi­
center clinical trial using the Titan device for skin tightening.
One of the authors (A.F.T) evaluated 42 patients after two
treatments at 4-week intervals. Mean improvement noted 3–4
months after the final treatment was 1.83 based on a quartile
grading scale (scale 0–4, with 4 denoting maximum improve­
ment). Over 90% of study subjects demonstrated visible im­
provement with no complications reported.
1064 nm Nd:YAG laser
Several studies23,24 have shown successful nonablative reju­
venation and skin ‘toning’ using a long-pulsed 1064 nm Nd:
YAG laser; however, there is a relative paucity of research de­
scribing its use for noninvasive tightening of skin laxity. In a
split-face study protocol, Taylor and Prokopenko25 evaluated
seven patients with mild to moderately lax facial skin. The
left side of the face was treated with a long-pulsed 1064 nm
Nd:YAG laser (GentleYAG, Candela Corp.) and the right side
was treated with monopolar RF energy (ThermaCool TC,
Thermage). The single split-face treatment utilized a triple-
pass technique for each device. Laser treatment parameters
(fluence 50 J/cm2, 10 mm spot size, 50 ms pulse duration,
2 Hz repetition rate, dynamic cooling 40/20 ms) remained
consistent for each study subject, as did the parameters for
the monopolar RF device (73.5 J/cm2, 150 pulses, 1 cm fast
tip). Clinical improvement in laxity and wrinkles was inde­
pendently evaluated by six masked observers from standard­
ized digital photographs. The authors concluded that after
a single treatment, both the long-pulsed 1064 Nd:YAG laser
and mono­polar RF device provided a modest degree of im­
provement in both wrinkles and laxity of facial skin. Improve­
ment was maintained for at least 2–6 months on both facial
halves. Additional studies evaluating the effectiveness of this
long-pulsed 1064 nm Nd:YAG laser for the treatment of skin
laxity are pending.35
Discussion
The ability to noninvasively tighten facial, neck, or body skin
is desired by many patients. Before 2002, treatment choices
for skin laxity included only invasive surgical procedures. As
technology has evolved, conditions that once required major
surgical intervention are gradually being replaced by mini­
mally invasive techniques. Monopolar and combination bi­
polar RF and diode laser devices, a near-infrared laser, and
a broadband mid-infrared light source have been introduced
to deliver noninvasive tissue tightening by volumetric dermal
heating. While controversy persists over the effectiveness and
consistency of these devices, their noninvasive nature, coupled
with their excellent side effect profiles, makes them attractive
alternatives to surgical lifting procedures in those patients with
mild-to-moderate skin laxity. Further technologic develop­
ments and refinement of treatment algorithms are warranted
to enhance our understanding and optimize treatment out­
comes of these noninvasive skin tightening procedures.
Procedures and techniques
Preoperative clinical ­considerations
For all cosmetic procedures, appropriate selection of pa­
tients is essential to ensuring satisfactory results. In one
study, ­ investigators36 noted that despite demonstrating sta­
tistically significant objective improvement in post-treatment
• Appropriate patient selection is essential to
a successful nonsurgical tissue tightening
­procedure.
• Clear informed consent outlining the limitations
of nonsurgical tissue tightening techniques is
mandatory prior to treatment.
• Standardized digital photographs of skin laxity
at baseline and every follow-up visit are a useful
tool to document clinical improvement.
• Advanced treatment protocols that describe the
use of multiple passes at sites of tissue laxity
with lower energies provide the most consistent
results with an excellent safety profile.
• Demonstration of the immediate tightening
effects of the treatment by providing a mirror
half-way through the procedure can increase
overall patient satisfaction with the technique.
• Treat to an end point of visible or palpable tissue
tightening.
• Follow-up appointments can help identify patient
concerns and increase the overall satisfaction
with treatment as clinical improvement can take
months for the patient to appreciate.
Pearls
• Poor communication regarding the limitations of
nonsurgical skin tightening techniques can lead
to a disappointed patient.
• Overtreatment with any of the nonsurgical skin
tightening devices can cause long-term side
effects and complications. Vesiculation as a
result of poor epidermal cooling or contour
defects secondary to excessive thermal injury
in the dermis can be avoided with the use of
proper technique.
Pitfalls

217
Nonsurgical tissue tightening  •  Chapter 15
­measurements of brow elevation from baseline, 64% of study
participants were not satisfied with monopolar RF treatment.
The objective clinical improvement juxtaposed with overall pa­
tient dissatisfaction suggests the patients were not provided with
a realistic expectation of results prior to the treatment. To avoid
this pitfall, it is imperative to communicate to the patient in
clear terms that noninvasive skin tightening techniques are not
an equal substitute for surgical lifting procedures. Nonsurgical
tissue tightening offers modest skin tightening as compared to
surgery and it is possible that a small percentage of patients fail
to demonstrate any improvement. Patients who cannot accept
the risk of minimal improvement or who desire more dramatic
results should be counseled to consider surgical alternatives.
Patients with an implanted medical device such as a pace­
maker or defibrillator are not candidates for radiofrequency
treatment. As with any other skin treatment, patients with
active dermatologic, collagen-vascular, or autoimmune prob­
lems should be carefully screened and counseled before treat­
ment. Patients with a strong history of herpes simplex virus
should receive oral antiherpetic prophylaxis if perioral treat­
ment is planned.
Prior to all nonsurgical skin tightening treatments, good-
quality, standardized photographs are essential. Pre- and
post-treatment photos should match in color, positioning, and
lighting in order to be of value to detect even subtle improve­
ments in skin laxity.
Informed consent must be obtained in all patients prior to
any nonsurgical skin tightening procedure (see Appendix A).
Although studies37–39 have shown monopolar RF treatments
delivered over dermal filler substances in both animal models
and human tissue does not cause immediate gross morpho­
logical changes in the filler material or surrounding skin, nor
untoward side effects, it is important to document the location
of dermal fillers prior to treatment should any unexpected
side effects develop.
Procedural techniques
Monopolar radiofrequency
Patients should remove all traces of makeup prior to monopo­
lar RF treatment. In the preoperative assessment, it is helpful
to view the face as two distinct areas: upper and lower face.
There may be some benefit to treating the entire face in one
session, but it is possible to treat either the forehead region
or the cheek/jawline region alone. Both treatment zones can
include treatment of the periorbital area.
Monopolar RF is capable of tightening skin and improv­
ing contours. The physician must analyze the patient’s three-
dimensional facial structure to assess those areas that would
benefit most from tightening.
Prior to treatment, the patient should be appropriately
grounded. A water-soluble ink grid of contiguous squares is ap­
plied to the treatment area (Fig. 15-9). The unique ­mono­polar
RF treatment tip is calibrated for each patient with a fine tun­
ing pulse. Coupling fluid is applied liberally to the treatment
site to ensure uniform conduction of energy from electrode to
skin. To allow proper epidermal cooling throughout the treat­
ment cycle and enable volumetric distribution of energy in the
treatment area, care must be taken to maintain full contact
of the treatment tip with the skin. Without complete tip con­
tact with the skin, the monopolar RF device will immediately
abort energy delivery.
During treatment, the patient is asked to grade the level of
discomfort on a 4-point scale (0 = no heat, 1 = warm, 2 = hot,
3 = very hot, 4 = intense heat). Energy levels are titrated to a
comfort goal of 2–2.5 to ensure a safe level of energy delivery.
While the original monopolar RF technique involved a single,
nonoverlapping high-energy pass that was often very uncom­
fortable for patients,27,28 the subsequent change in treatment
algorithm involving multiple low-energy passes has rendered
the procedure more tolerable. Furthermore, the development
of faster and larger treatment tips has allowed the application
of multiple-pass treatment algorithms without adding to the
total procedure time. The most recent treatment algorithms
discourage the use of systemic (general or i.v. sedation) or
topical anesthesia that may blunt the patient’s sensation of
pain. It has also been speculated that topical anesthesia can
exacerbate discomfort during treatment by selectively numb­
ing the epidermis and mitigating the soothing (cooling) effect
of the cryogen without altering the deep heating sensation
that penetrates to the level of the dermis.40 Therefore, mild
oral analgesics and/or short-acting anxiolytics taken prior to
the procedure may best improve patient comfort during the
procedure while allowing the treating physician to gauge the
patient’s response to treatment.
The choice of treatment setting is determined by the
location and thickness of skin within the treatment grid.
Fig. 15-9  Placement of the temporary ink grid prior to monopolar
radiofrequency treatment.

218
Chapter 15
Cosmetic surgery procedures and techniques
Lower ­energy levels are required in areas of thinner skin,
over vulnerable areas with small amounts of subcutane­
ous fat (malar prominence, temples, neck), and over areas
of known nerve distribution (greater auricular, infraorbital,
supraorbital mental).
Using a 3 cm2 treatment tip, most patients are treated with
levels ranging 353–356 depending on the patient’s response
to the 4-point pain scale. Energy levels are titrated in incre­
ments of 0.5 until the patient feels comfortable. Reports of
extreme pain in a given area should be interpreted as an
indication of excessive heat production, regardless of treat­
ment level. Two to three initial passes are performed over
the entire skin region using the ink grid to ensure complete
coverage. Additional passes are then performed over areas
of prominent skin laxity, such as the mandible (jowls), sub­
mental fat pad, and infraorbital regions. Up to 10 passes can
be delivered safely to these regions provided the patient is
not reporting intolerable pain during treatment. The final
passes are delivered to promote immediate contraction of the
­subdermal fibrous septae. Patients are treated to an end point
of visible or palpable skin tightening. Depending on the sur­
face area of the face, up to 600 pulses can be delivered to the
mid- and lower face and mandible, and 300–400 pulses to the
brow and periorbital region. It can be particularly helpful to
treat an entire facial half prior to treatment of the contralat­
eral side in order to have the patient visualize the immediate
tissue tightening that is typically apparent immediately post-
treatment (Figs 15-10, 15-11).
Nonfacial areas that require skin tightening can also be
treated successfully with the monopolar RF device using the
3 cm2 treatment tip (Fig. 15-12). The number of passes and
total number of pulses will depend on the surface area that
A
B
Fig. 15-10  (A) Cheek laxity, pretreatment. (B) Clinical tightening noted 6 months after a single monopolar radiofrequency treatment (ThermaCool TC).
A
B
Fig. 15-11  (A) Infraorbital tissue laxity, pretreatment. (B) Clinical tightening noted 6 months after a single monopolar radiofrequency treatment
(ThermaCool TC).

219
Nonsurgical tissue tightening  •  Chapter 15
requires treatment (Table 15-1). As with treatment on the face,
energy levels are titrated according to patient tolerance based
on the 4-point scale.
Dermatochalasis represents one of the newest indica­
tions for noninvasive skin tightening with the monopolar RF
­device.41 After ocular anesthesia is obtained using a topi­
cal ophthalmic solution, a specialized ink grid is applied to
the upper eyelid and periocular region. Plastic, nxot metal,
eyeshields are required during monopolar RF ­ treatment.
­Although sand-blasted metal eyeshields are necessary ­during
ablative laser procedures performed in proximity to the
eye, they are not appropriate for use with monopolar RF
treatment due to propagation of the RF energy through the
metal to the globe, resulting in ocular injury. A 0.25 cm2 treat­
ment tip with a shallow heating profile is suggested for use
on eyelid skin over the globe. Upon treatment initiation, low
­energies (32.0) are applied with titration of the energy level to
a ‘2–2.5’ on the 4-point heat sensation scale. Two full passes
are typically performed over each upper eyelid, with addi­
tional passes applied as necessary. Mild erythema and edema
is an expected end point of treatment. To finish the treatment,
a 1.5 cm2 tip is used to treat the remainder of the periocular
region, outside the orbital rim, with 3–6 passes delivered to an
end point of visible tissue tightening.
Combination bipolar radiofrequency
and diode laser
Prior to treatment initiation, all makeup is removed and topi­
cal anesthetic cream may be used on the treatment area to im­
prove patient comfort. After adequate eye protection is placed
on the patient and all medical personnel present, an aqueous
conducting gel is applied to the skin and three or four con­
secutive nonoverlapping passes are delivered to the treatment
area. Diode energy levels of 30–50 J/cm2 and biopolar RF
­energy levels of 80–100 J/cm2 are most commonly used on
the face. Treatment parameters are adjusted to produce im­
mediate mild erythema and edema of the skin without signs
of epidermal damage (vesiculation). Radiofrequency energies
are lowered by 10% for treatment of the forehead and peri­
ocular regions. Typically, a series of three to five treatment ses­
sions are performed at monthly intervals. At each subsequent
treatment session, the energies can be increased by 5–10%
as indicated by the patient’s immediate clinical ­response and
pain tolerance (Fig. 15-13).
Broadband infrared light source
Prior to treatment, patients are directed to remove all makeup.
Once adequate protective goggles are placed on the patient
and medical staff, two initial passes are delivered to the
­areas of skin laxity. A typical treatment includes fluences of
30–40 J/cm2 on the face and 32–40 J/cm2 on areas of nonfa­
cial skin laxity. The fluence is titrated to patient tolerance. Ad­
ditional passes are performed over areas with excessive laxity
on the face, neck, and abdomen. The identification of vectors
for lifting purposes are identified by pulling on the skin in the
direction of correction desired and finding the best location
of ‘pull.’ The identified vectors are targeted for additional
­focused passes. The number of pulses for a full-face treatment
can vary from 200 to 300 depending on the number of passes
performed and treatment surface area. For tightening of the
A
B
Fig. 15-12  (A) Abdominal skin laxity, pretreatment. (B) Skin tightening continued 12 months after a single monopolar radiofrequency treatment
(ThermaCool TC).
Table 15-1  Mean number of pulses delivered during monopolar
radiofrequency treatment
Treatment area
Number of pulses
Full face
700–900
Upper face (periorbital and brow)
300–400
Lower face (cheeks, ­mandible,
submentum)
450–600
Upper arms
600–900
Abdomen
900–1200

220
Chapter 15
Cosmetic surgery procedures and techniques
abdomen, the number of pulses will depend on the surface
area that requires treatment (Table 15-2). Visible and palpa­
ble firming and tightening in the treated areas is the desired
end point of treatment. At any point during treatment, an
intense burning sensation described by the patient may indi­
cate ­incomplete contact with the cooling sapphire ­handpiece.
If this occurs, the patient should be monitored closely for
signs of epidermal injury and managed appropriately. Cur­
rent treatment recommendations with the broadband in­
frared device call for two treatments at 1–3 month intervals
(Figs 15-14, 15-15).
1064 nm Nd:YAG laser
Patients are instructed to remove all cosmetic residue prior
to treatment. Topical anesthetic cream and oral analgesics
can be used to increase patient comfort during the procedure.
After protective goggles are placed on the patient and medical
staff, outlined treatment areas receive three nonoverlapping
passes with the 1064 nm Nd:YAG laser using the following
treatment parameters: 10 mm spot size, 50 J/cm2, 50 ms pulse
duration, and 2 Hz repetition rate. The epidermis is protected
during treatment with a cryogen dynamic cooling device
(40/20 ms). Mild erythema and edema are noted at end of
A
B
Fig. 15-14  (A) Cheek and mandibular skin laxity, pretreatment. (B) Clinical improvement noted 6 months after two broadband infrared light
treatments (Titan). (Photographs courtesy of Maritza Perez, M.D.)
A
B
Fig. 15-13  (A) Periorbital skin laxity and rhytides, pretreatment. (B) Clinical improvement noted 3 months after three bipolar radiofrequency
and diode laser treatments (Polaris WR).
Table 15-2  General parameters for broadband infrared light
­treatment
Treatment area
Fluence (J/cm2)
Total pulses
Lower face
(cheeks/mandible)
32–40
200–300
Upper face
(­periocular/brow)
30–36
100–150
Abdomen
34–40
300–450

221
Nonsurgical tissue tightening  •  Chapter 15
treatment. Up to four consecutive treatments are delivered at
4-week ­intervals (Fig. 15-16).
Postoperative clinical ­considerations
Post-treatment Instructions
Since the epidermis remains intact following nonsurgical
skin tightening procedures, the need for postoperative care is
­minimal. Nearly all patients are immediately able to resume
normal activities. A mild deep heating sensation may be ex­
perienced after treatment, but is typically resolved within 2
hours. Transient, mild erythema and edema can also occur,
with spontaneous resolution within 24 hours. In the unlikely
event of epidermal injury (most often due to inadequate epi­
dermal cooling during treatment), standard wound treatment
procedures can be implemented.
In the weeks following a noninvasive skin tightening pro­
cedure, follow-up office evaluations can help identify patient
concerns and increase overall treatment satisfaction. Clinical
improvement after treatment may take weeks to months to
A
B
Fig. 15-15  (A) Abdominal skin laxity, pretreatment. (B) Clinical tightening noted 6 months after two broadband infrared light treatments (Titan).
(Photographs courtesy of Maritza Perez, M.D.)
Fig. 15-16  Clinical tightening noted after a series of long-pulsed
1064 nm Nd:YAG laser treatments (GentleYAG). (Photograph cour­
tesy of Mark Taylor, M.D.)
Fig. 15-17  Erythematous nodules noted 1 week after monopolar
radiofrequency treatment.

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Chapter 15
Cosmetic surgery procedures and techniques
realize, thus reassurance by the treating physician regarding
the patient’s progress can be particularly important.
Side effects
The incidence of side effects with monopolar RF treat­
ment is low. Transient post-treatment erythema and edema
are common; however, erythematous papules that persist
for days or superficial burns are rare (Fig. 15-17). Despite
protective mechanisms built into the treatment tips, uneven
electrode contact with the skin (as a result of facial contours
or patient movement during treatment) results in arcing of
monopolar RF energy and subsequent epidermal injury.
Until 2004, rare occurrences (0.08% of 161 000 cases) of
tissue irregularities and ridging related to excessive thermal
injury in the dermis were reported. The promulgation of
the most advanced treatment algorithm involving delivery
of low fluences with multiple passes over targeted areas
has been associated with even fewer contour irregularities
(0.03%).17 Subcision and ­autologous fat transfer has been
used to correct dermal depressions related to RF overtreat­
ment.42 Temporary altered sensation of treated skin has also
been described.8
The combination biopolar RF and diode laser device is
generally well tolerated. Vesiculation as a result of inadequate
epidermal cooling during treatment has been reported in
3–10% of patients, and generally resolves without dyspigmen­
tation or textural irregularities within 5 days.19,32,33
Immediately after treatment with the broadband infrared
device, mild erythema and edema is expected. Superficial, ep­
idermal burns that heal without sequelae have been reported
and are likely due to insufficient epidermal cooling due to
handpiece positioning. However, rare cases of significant full-
thickness skin injury have been described as a complication of
bulk heating using this broadband infrared device.43 Possible
contributing factors include improper position of the hand­
piece, excessive or incorrect treatment parameters, or greater
propagation of heat over bony structures with subsequent
nonselective thermal injury to the skin.
There have been no reports of serious side effects or
­complications using the long-pulsed 1064 nm Nd:YAG laser
for noninvasive skin tightening. The use of this device as an
effective skin tightening procedure is relatively new, with few
clinical studies to date.25 It would be expected that any skin
tightening device, when used with improper technique or
at excessive treatment parameters, has the potential for side
­effects and long-term complications.
REFERENCES
  1. Alster TS. Cutaneous resurfacing with CO2 and erbium:YAG lasers:
preoperative, intraoperative, and postoperative considerations. Plast
Reconstr Surg 1999; 103:619–632.
  2. Tanzi EL, Alster TS. Side effects and complications of variable-pulsed
erbium:YAG laser skin resurfacing: extended experience with 50
patients. Plast Reconstr Surg 2003; 111:1524–1529.
  3. Alster TS, Tanzi EL. Laser skin resurfacing: ablative and nonablative. In
Hanke W, Robinson J, eds. Surgery of the skin. Philadelphia: Elsevier;
2004:611–624.
  4. Goldberg DJ. Full-face nonablative dermal remodeling with a 1320 nm
Nd:YAG laser. Dermatol Surg 2000; 26:915–918.
  5. Tanzi EL, Williams CM, Alster TS. Treatment of facial rhytides with
a nonablative 1450 nm diode laser: a controlled clinical and histologic
study. Dermatol Surg 2003; 29:124–128.
  6. Goldberg DJ, Cutler KB. Nonablative treatment of rhytides with intense
pulsed light. Lasers Surg Med 2000; 26:196–200.
  7. Fitzpatrick R, Geronemus R, Goldberg D, et al. Multicenter study of
noninvasive radiofrequency for periorbital tissue tightening. Lasers Surg
Med 2003; 33:232–242.
  8. Alster TS, Tanzi E. Improvement of neck and cheek laxity with a
nonablative radiofrequency device: a lifting experience. Dermatol Surg
2004; 30:503–507.
  9. Iyer S, Suthamjariya K, Fitzpatrick RE. Using a radiofrequency energy
device to treat the lower face: a treatment paradigm for a nonsurgical
facelift. Cosmet Dermatol 2003; 16:37–40.
10. Ruiz-Esparza J, Gomez JB. The medical face lift: a noninvasive,
nonsurgical approach to tissue tightening in facial skin using nonablative
radiofrequency. Dermatol Surg 2003; 29:325–332.
11. Narins DJ, Narins RS. Non-surgical radiofrequency facelift. J Drugs
Dermatol 2003; 2:495–500.
12. Hsu TS, Kaminer MS. The use of nonablative radiofrequency
technology to tighten the lower face and neck. Semin Cutan Med Surg
2003; 22:115–123.
13. Ruiz-Esparza J. Noninvasive lower eyelid blepharoplasty: a new
technique using nonablative radiofrequency on periorbital skin.
Dermatol Surg 2004; 30:125–129.
14. Finzi E, Spangler A. Multpass vector (mpave) technique with
nonablative radiofrequency to treat facial and neck laxity. Dermatol
Surg 2005; 31:916–922.
15. Nahm WK, Su TT, Rotunda AM, et al. Objective changes in brow
position, superior palpebral crease, peak angle of the eyebrow, and jowl
surface area after volumetric radiofrequency treatments to half of the
face. Dermatol Surg 2004; 30:922–928.
16. Tunnel JW, Pham L, Stern RA, et al. Mathematical model of
nonablative RF heating of skin. Lasers Surg Med 2002; 14:318.
17. Jacob CI, Kaminer MS. Skin tightening with radiofrequency. In: Dover
JS, Alam M, Goldberg D, eds. Procedures in cosmetic dermatology
series: laser skin surgery, vol. 2. Philadelphia: Elsevier; 2005:43–60.
18. Zelickson BD, Kist D, Bernstein E, et al. Histological and ultrastructural
evaluation of the effects of a radiofrequency-based non-ablative dermal
remodeling device: a pilot study. Arch Dermatol 2004; 140:204–209.
19. Sadick SN, Trelles MS. Nonablative wrinkle treatment of the face and
neck using a combined diode laser and radiofrequency technology.
Dermatol Surg 2005; 31:1695–1699.
20. Ruiz-Esparza J. Painless, nonablative, immediate skin contraction
induced by low-fluence irradiation with new (sic) infrared device: a
report of 25 patients. Dermatol Surg 2006; 32:601–610.
21. Dierickx CC. The role of deep heating for noninvasive skin
rejuvenation. Lasers Surg Med 2006; 38:799–807.
22. Zelickson B, Ross V, Kist D, et al. Ultrastructural effects of an infrared
handpiece on forehead and abdominal skin. Dermatol Surg 2006;
32:897–901.
23. Dayan SH, Vartanian J, Menaker G, et al. Nonablative laser resurfacing
using the long-pulse (1064 nm) Nd:YAG laser. Arch Facial Plast Surg
2003; 5:310–315.
24. Lee CMW. Combination 532 nm and 1064 nm lasers for noninvasive
skin rejuvenation and toning. Arch Dermatol 2003; 139:1265–1276.
25. Taylor MB, Prokopenko I. Split-face comparison of radiofrequency
versus long-pulse Nd:YAG treatment of facial laxity. Cosmetic Laser
Ther 2006; 8:17–22.
26. Kushikata N, Negishi K, Tezuka Y, et al. Non-ablative skin tightening
with radiofrequency in Asian skin. Lasers Surg Med 2005; 36:92–97.
27. Fritz M, Counters JT, Zelickson BD. Radiofrequency treatment for
middle and lower face laxity. Arch Facial Plast Surg 2004; 6:370–373.

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Nonsurgical tissue tightening  •  Chapter 15
28. Kist D, Burns AJ, Sanner R, et al. Ultrastructural evaluation of multiple
pass low energy versus single pass high energy radiofrequency treatment.
Lasers Surg Med 2006; 38:150–154.
29. Burns AJ, Holden SG. Monopolar radiofrequency tissue tightening –
how we do it in our practice. Lasers Surg Med 2006; 38:575–579.
30. Weiss RA, Weiss MA, Munavalli G, et al. Monopolar radiofrequency
facial tightening: a retrospective analysis of efficacy and safety in over
600 treatments. J Drugs Dermatol 2006; 5:707–712.
31. Fisher GH, Jacobson LG, Bernstein LJ, et al. Nonablative
radiofrequency treatment of facial laxity. Dermatol Surg 2005;
31:1237–1241.
32. Doshi SN, Alster TS. Combination radiofrequency and diode laser for
treatment of facial rhytides and skin laxity. Cosmetic Laser Ther 2005;
7:11–15.
33. Kulick M. Evaluation of a combined laser-radiofrequency device
(Polaris WR) for the nonablative treatment of facial wrinkles. Cosmetic
Laser Ther 2005; 7:87–92.
34. Taub AF, Battle EF Jr, Nikolaidis G. Multicenter clinical perspectives on
a broadband infrared light device for skin tightening. J Drugs Dermatol
2006; 5:771–778.
35. Key DJ. Long pulsed Nd:YAG laser enhances skin lifting and tightening
over monopolar RF treatment. Lasers Surg Med 2006; S18:95.
36. Bassichis BA, Dayan S, Thomas JR. Use of a nonablative
radiofrequency device to rejuvenate the upper one-third of the face.
Otolaryngol Head Neck Surg 2004; 130:397–406.
37. Alam M, Levy R, Pavjani R, et al. Safety of radiofrequency treatment
over human skin previously injected with medium-term injectable soft-
tissue augmentation materials: a controlled pilot study. Lasers Surg Med
2006; 38:205–210.
38. Shumaker PR, England LJ, Dover JS, et al. Effect of monopolar
radiofrequency treatment over soft-tissue fillers in an animal model:
part 2. Lasers Surg Med 2006; 38:211–217.
39. Goldman MP, Alster TS, Weiss R. A randomized trial to determine
the influence of laser therapy, monopolar radiofrequency treatment,
and IPL therapy administered immediately after hyaluronic acid gel
implantation. Dermatol Surg 2007; 33:535–542.
40. Kushikata N, Negishi K, Tezuka Y, et al. Is topical anesthesia useful in
noninvasive skin tightening using radiofrequency? Dermatol Surg 2005;
31:526–533.
41. Beisman BS, Carruthers J, Baker S, et al. Monopolar RF treatment of
human eyelids: a prospective evaluation. Lasers Surg Med 2006; S18:94.
42. Narins RS, Tope WD, Pope K, et al. Overtreatment effects associated
with a radiofrequency tissue tightening device: rare, preventable, and
correctable with subcision and autologous fat transfer. Dermatol Surg
2006; 32:115–124.
43. Narukar V. Full thickness permanent scars from bulk heating using an
infrared light source. Lasers Surg Med 2006; S18:96.

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Cosmetic surgery procedures and techniques
Appendix A
Thermage or Polaris (Radiofrequency) Treatment Consent Form
Dr. ____________________ has explained to me that I am an appropriate candidate for a nonsurgical skin tightening procedure.
I understand that this treatment is FDA-approved and studies have shown it to be safe and effective for skin tightening in all skin
types. The clinical results from a single radiofrequency treatment appear to be long-standing, but additional treatments can be
delivered for further skin tightening if desired.
I further understand that the radiofrequency procedure has possible associated side effects, including (but not limited to):
1.  Deep heating sensation of the skin during treatment
2.  Tension headache
3.  Skin redness
4.  Mild swelling
5.  Tenderness
6.  Temporary altered sensation of treated skin
7.  Transient bumps under the skin
8.  Blistering or pigmentary change (rare)
9.  Textural changes or surface irregularities (rare)
Final treatment results often take 3 to 6 months to observe. There is no guarantee that I will benefit from treatment, but subtle
skin tightening is expected.
Initial below if any of the following apply:
_______ Previous permanent filler injections (circle any/all as appropriate)

Silicone, Artefill, Radiance, other _______

Body location(s)/dates of treatment _______
_______ Presence of pacemaker (date of placement _______)
_______ Metal facial implant or surgical staples (date:_______, location:_______)
By providing my signature below, I acknowledge that I have read and understood all the information outlined above and that no
misrepresentations of my medical history have been made. I have had all of my questions answered to my complete satisfaction.
I hereby freely consent to the radiofrequency procedure to be performed by ���������
_______��.
_______________________________________
_________________________________________
Patient Signature
Date
Witness Signature
Date
_______________________________________
Physician Signature
Date

History and Science
History
Until the advent of laser resurfacing, treatment options for
photodamaged skin were limited to the application of various
surgical and chemoexfoliation techniques aimed at ­removing
the outer layers of skin. The ancient Egyptians used ­ lactic
acid, an ingredient of sour milk, as a chemoexfoliant to re­
move superficial layers of stratum corneum and promote skin
rejuvenation.1 In the Middle Ages, old wine with tartaric acid
was used for the same purpose.1 In 1905, Kromayer first re­
ported controlled abrasion of the skin using rotating wheels
and rasps for the treatment of acne scars, keratoses, and areas
of hyperpigmentation.2 In the mid-twentieth century, derma­
brasion became particularly popular for its ability to improve
surface textural irregularities. However, the procedure had
often inconsistent results and a high rate of complications
­depending on the skill of the operating surgeon.3,4
In the early 1960s, Kumar Patel began carrying out fun­
damental research on laser action through pure gases at Bell
Laboratories. Within 3 years he developed the carbon diox­
ide (CO2) laser, the first gas laser to produce continuous-wave,
high-power radiation.5 Much of the early work in the use
of the carbon dioxide laser applications in dermatology was
done by Elizabeth McBurney and Phil Bailin and colleagues
for the treatment of various cutaneous disorders and tattoo
removal.6,7 In the late 1980s, it was discovered that using la­
ser technology for skin resurfacing yielded more predictable
depths of injury when compared to either chemical peels or
dermabrasion. The first laser used for skin resurfacing was a
continuous-wave CO2 laser. While results were promising, ex­
cessive thermal injury in the dermis produced an unacceptable
risk of scarring.8 Goldman et al. used a pulsed carbon dioxide
laser that was modified from a device developed for otolaryn­
gological and gynecological use. Its cosmetic uses were initially
limited to the treatment of periorbital and perioral rhytides,
but dramatic clinical results quickly led to its use for full-face
resurfacing.9
The short-pulsed erbium:yttrium-aluminum-garnet (Er:
YAG) laser was developed in the mid-1990s as an alternative
to the pulsed CO2 laser and first introduced as a bone-cutting
tool in the United States.10 Its name derives from the Swed­
ish town of Ytterby, which is the site of a quarry where the
rare-earth elements erbium and yttrium were discovered. The
cutaneous absorption of the Er:YAG laser energy by water
is over tenfold more efficient than that of the carbon dioxide
laser, allowing for more superficial tissue ablation and finer
Ablative and Microablative
Skin Resurfacing
Melissa A. Bogle,
Jeffery S. Dover, and
Kenneth A. Arndt
C h a p t e r
16
p a r t 2
Key Points
n There are three categories of ablative ­resurfacing,
including laser skin resurfacing (CO2 and Er:YAG),
fractional photothermolysis, and plasma skin
­regeneration.
n Traditional laser skin resurfacing offers the most
dramatic results, but can have extensive downtime
of 2 or more weeks.
n Fractional photothermolysis was developed to
­approach the clinical efficacy of traditional ­laser
­resurfacing with less recovery time and
an ­improved side effect profile.
n Plasma skin regeneration uses nitrogen plasma
energy to heat the skin without reliance on
­chromophores, causing tissue remodeling and new
collagen formation.

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Cosmetic surgery procedures and techniques
control. However, the laser has poor intraoperative ­hemostasis
and less impressive clinical improvement when compared to
traditional high-energy pulsed or scanned carbon dioxide
­laser resurfacing. Modulated (short-and-long-pulsed) Er:YAG
devices were developed in an attempt to achieve deeper abla­
tion of tissue, improved hemostasis, and increased collagen
remodeling by means of thermal injury.
The CO2 and Er:YAG lasers are effective in the treatment
of sun-induced wrinkles, brown spots, and skin laxity, but have
a disadvantage in that they require a high level of operator
skill to avoid complications such as scarring, dyspigmenta­
tion, and lines of demarcation between treated and untreated
­areas. They also require meticulous postoperative care by the
patient and have downtime periods of a week or more with
oozing and denuded skin.
The concept of fractional photothermolysis was ­introduced
in 2004 in an attempt to deliver results approaching that of tra­
ditional ablative laser resurfacing, without the associated risks
and lengthy recovery period (Fig. 16-1).11 Whereas ­traditional
laser resurfacing removes the entire top layer of the skin sur­
face, creating a visible wound and loss of the skin’s protective
function, fractional laser resurfacing treats a small ‘fraction’ of
the skin at each session. Intact, undamaged skin around each
treated area theoretically acts as a barrier to infection and a
reservoir for rapid healing.
Each of the above treatments relies on the principles of sel­
ective photothermolysis to selectively target water-containing
tissue and effect controlled tissue vaporization. Plasma skin re­
generation is a recently developed technology that uses pulses
of ionized inert nitrogen gas to deliver heat energy directly to
the skin. Unlike lasers, there is no reliance on a specific tar­
get such as water, hemoglobin, or pigment. The ­nitrogen gas
flushes oxygen from the treatment area, so there is no charring,
and the skin remains in place to act as a ­biologic dressing on the
treated area. This simplifies ­postoperative care and decreases
the risk of adverse effects such as infection and scarring.
Science
There are four major modalities for ablative skin ­resurfacing,
including laser resurfacing, microablative or fractional photo­
thermolysis, and plasma devices. The two main ablative laser
technologies are the carbon dioxide (CO2) laser with a wave­
length of 10 600 nm and the erbium:yttrium-­aluminum-garnet
(Er:YAG) laser with a wavelength of 2940 nm.
The carbon dioxide laser emits light at a wavelength of
10 600 nm, targeting both intracellular and extracellular ­water
based on the principles of selective photothermolysis.12 CO2 la­
sers can be operated in a focused mode with high ­irradiance to cut
tissues in a nearly bloodless fashion, or in a defocused, low-power
mode to ‘resurface’ superficial ­layers of tissue. Tissue vaporiza­
tion occurs when light energy is ­absorbed by water-containing
tissue. With traditional continuous-wave ­lasers, nearly 90% of
the laser energy is absorbed in the initial 25–50 μm of ablated
skin; however, there is a thick zone of coagulative necrosis in
the dermis measuring 20–100 μm.13 The relationship between
number of laser passes and tissue ablation/thermal damage is
not linear. The first pass ablates significantly more tissue than
the second or subsequent passes. An ablation plateau is reached
at around 3–4 passes, limiting ablation depth to approximately
250 μm. Thermal damage, however, is cumulative with each
­additional laser pass, ­resulting in a wider zone of necrosis.
Pulsed carbon dioxide lasers with a pulse duration of
less than 1 ms selectively vaporize 25–50 μm of tissue in one
pass with a thin zone of residual thermal necrosis measuring
­approximately 40–120 μm.14 This zone of thermal necrosis is
sufficient enough to seal off dermal blood vessels and lym­
phatics, yet narrow enough to reduce the incidence of scar
formation. Other carbon dioxide lasers use an optomechanical
shutter system connected to a conventional continuous-wave
carbon dioxide laser. This scanner distributes laser energy into
a train of pulses with a dwell time shorter than the thermal
relaxation time of skin, thus mimicking pulsed carbon dioxide
lasers. Newer ‘ultrapulse’ carbon dioxide lasers with very short
pulse durations ablate less tissue per pass and leave behind
a narrower zone of thermal necrosis than original carbon
­dioxide resurfacing lasers. Some systems have a computerized
pattern generator (CPG) that rapidly and precisely places
­individual laser pulses in a pattern array selected by the user.
Cosmetic improvement after laser resurfacing is attribut­
able to several causes. Tissue ablation from successive laser
passes directly decreases the peaks and troughs of rhytides
and textural abnormalities via tissue vaporization at the sur­
face, thermal coagulation of cells in the dermis, and dena­
turation of extracellular matrix proteins.15 Immediate skin
contraction of 20–25% is visible during the procedure as a
result of tissue shrinkage from dehydration and contracted
collagen; however, most of the long-term benefits in skin
­rejuvenation appear to be from the delayed wound healing
Increasing recovery time
Increasing results
Er:YAG resurfacing
Low energy
plasma skin regeneration
Fractional
photothermolysis
High energy
plasma skin
regeneratiion
CO2 resurfacing
Non-ablative resurfacing
Fig. 16-1  Graphic illustrating degree of improvement versus
recovery time for various resurfacing procedures. The CO2 laser
remains the gold standard for notable results, but also has the most
downtime. Nonablative resurfacing has the least recovery time, but
also typically the least striking results.

227
Ablative and microablative skin resurfacing  •  Chapter 16
response.13,16 Postprocedure, the vaporized epidermal cells
are replaced with normal, well-organized keratinocytes from
the follicular adnexa. Disorganized solar elastosis in the upper
dermis is replaced with regenerated, compact collagen and
elastin organized in parallel configurations.17 Clinically, this
manifests as improved skin texture with fewer rhytides and
reduced dyspigmentation.
The Er:YAG laser contains a YAG crystal doped with er­
bium gas which may be excited by a pulsed flashlamp. It emits
light at a wavelength of 2940 nm which targets both intra- and
extracellular water in a similar fashion as the CO2 laser. The
main difference between the two lasers is that the wavelength
of the Er:YAG laser is absorbed 12–18 times more efficiently
by water-containing tissue than the wavelength of the CO2
laser. When water-containing tissues absorb energy from the
Er:YAG laser, there is an immediate expulsion of the desic­
cated tissue, resulting in a characteristic ‘popping’ sound. The
immediate conversion of light energy to mechanical energy is
important because there is very little thermal collateral dam­
age. There is no char formation, only a transient white dis­
coloration of the wound bed. Dermal vessels in the treatment
area dilate and transudate fluid, increasing the water content
in the treated area and allowing for consistent ablation with
each subsequent pass.18 In contrast, energy from the CO2
laser is transformed into a thermomechanical energy that
ablates superficial tissue, destroys dermal vessels, and dena­
tures dermal proteins. A typical short-pulse Er:YAG laser with
a pulse duration of 250 μs and a fluence of 5 J/cm2 ablates
15–20 μm of tissue per pass with minimal residual thermal dam­
age, compared to 25–50 μm of ablated skin and 20–100 μm
of residual thermal damage with the CO2 laser.13
Precise tissue ablation and a relatively small zone of resid­
ual thermal damage results in faster reepithelialization and an
improved side effect profile, but less dramatic clinical results.
Immediate collagen contraction during the procedure is only
1–2% and may only reach 14% in the long term.19 Patients
in the most favorable preoperative categories generally show a
50% improvement in rhytides and skin lesions. Whereas col­
lagen remodeling and clinical improvement often continue for
up to 18 months after CO2 resurfacing, full improvement is
generally seen by 12 months with the Er:YAG laser due to the
reduced thermal effect.20 Thus, the CO2 laser is a more reli­
able modality for deeper tissue ablation than the short-pulsed
Er:YAG laser, and can produce the same effect with better
hemostasis in one-third of the number of passes.19
Newer Er:YAG lasers offer variable pulses. The Er:YAG
pulse duration can be varied from a shorter (0.5 ms) pulse
that is used for tissue ablation to a longer (4 ms) pulse that is
used to induce collagen contraction through thermal injury.
The variable-pulse Er:YAG has the potential for better tissue
­penetration and deeper zones of thermal necrosis, resulting
in improved collagen contraction and tissue remodeling.21,22
The first fractional rejuvenating laser developed (Fraxel SR,
Reliant Technologies Inc., Mountain View, CA) uses a diode
pumped erbium fiber laser which emits light at a wavelength
of 1540 nm, targeting water in the skin. The beam is delivered
through an optically tracked, microprocessor controlled hand­
piece to produce an array of microscopic treatment zones
(MTZs), each about 100 μm in diameter, or about the size of
a human hair. During each treatment, 125 or 250 columns of
MTZs are created per square centimeter per pass, depending
on operator settings (Fig. 16-2). A water-soluble dye applied
in a thin layer to the treatment area allows the laser’s optical
tracking system to detect contact with the skin and adjust the
laser repetition rate depending on hand velocity (Fig. 16-3).
Fig. 16-2  The pixel-like marks were made as the fractional photo­
thermolysis handpiece was traced along a sheet of marking paper.
On the surface of the skin, each ‘pixel’ would be a column of thermal
injury termed a microscopic treatment zone (MTZ).
Fig. 16-3  Before fractional photothermolysis, the treatment area
is covered with a water-soluble blue dye (OptiGuide™ Blue, Reli­
ant Technologies, Mountain View, CA) which allows the laser’s
­optical tracking system to detect contact with the skin and adjust
the ­pattern of microscopic treatment columns with respect to hand
velocity. An upgrade to the optical tracking system in the ­second-
generation Fraxel SR1500 has made the blue contrast agent no
longer necessary.

228
Chapter 16
Cosmetic surgery procedures and techniques
When the handpiece moves more quickly, the laser repetition
rate is higher, and when the handpiece moves more slowly, the
laser repetition rate is lower. This assures a uniform, repro­
ducible pattern of microscopic treatment columns.
Treatment columns are about 400–700 μm deep, in con­
trast to the typical 200–300 μm depth of multiple-pass CO2
resurfacing. A zone of normal skin surrounds each microscopic
treatment column, leaving the barrier function of the epider­
mis intact and no visible wounding. The normal intervening
tissue allows for rapid reepithelialization by keratinocyte mig­
ration into the treatment column. After 2–3 days, the tops of
the wounded areas are shed as microepidermal necrotic debris
(MENDs) (Fig. 16-4). Further collagen remodeling continues
in the microscopic zone over the next 3–6 months. Each ses­
sion treats about 20% of the skin surface, so four to six treat­
ments are needed for best results.
The second-generation Fraxel SR1500 device was re­
leased in 2006 and employs a telescoping mechanism which
increases the beam diameter with higher fluences. This results
in a significant reduction in both epidermal disruption and
discomfort while at the same time providing greater depth of
thermal injury with associated therapeutic benefit. The device
is cleared for treatment energies up to 70 mJ and is capable
of creating superheated columns up to 1400 μm in depth.
Software updates to the optical tracking system and contact
­motion sensors have eliminated the need for application of a
blue contrast agent.
Several companies are now incorporating the fractional con­
cept into laser technology. Presently, two different approaches
are being taken. The first approach delivers columns of laser
light to the skin to fractionally heat and irreversibly damage
the epidermis and high dermis using and Er:YAG laser de­
livered through a multilensed handpiece (1540 nm Fractional
Er:YAG, Palomar Medical Technologies Inc., ­ Burlington,
MA and 1440 nm YAG laser, Affirm, Cynosure Inc., Westford
MA). The second approach uses a fractional infrared hand­
piece to deliver noncoherent light in the 825–1350 nm range
as a regular array of small hyperthermic beams with contact
cooling to heat the deep dermis to induce collagen change
and skin tightening (StarLux Fractional IR, Palomar Medical
Technologies, Inc., Burlington, MA).
The most recent development in the fractionated delivery
systems is the concept of ablative fractional rejuvenation (AFR)
otherwise known as fractional deep dermal ablation (FDDA
or FDA). This system, developed by Reliant, uses fractional
delivery of a CO2 laser and has been demonstrated to cause
visible tissue shrinkage and volumetric reduction. Results are
midway between traditional CO2 resurfacing and nonablative
lasers. The system is associated with a shorter recovery period
and fewer postoperative complications such as redness, scar­
ring, and persistent loss of pigmentation. Sciton (Palo Alto,
CA) has also developed a fractional Er:YAG laser with inter­
esting features. While 9-month results indicated good tissue
tightening with these devices, it is too early to assess the long-
term benefits of either of these systems.
It is necessary for laser engineers and laser surgeons to be
careful to define what they mean by fractional, since many
companies are now claiming ‘fractional’ treatment. In essence,
fractional should be defined as ultrahigh energy delivered in a
highly focused manner. This creates an event in the skin which
is unlike traditional delivery of lower fluences and leads to
deep dermal tissue remodeling.
Plasma skin regeneration (PSR) technology uses energy
delivered from plasma rather than light or radiofrequency.
Plasma is the fourth state of matter in which electrons are
stripped from atoms to form an ionized gas. The plasma
is emitted in a millisecond pulse to deliver energy to target
­tissue upon contact without reliance on skin chromophores
(Fig. 16-5). Although high-temperature plasmas have been
Plasma formation
Plasma out
Ultra high frequency
(UHF) energy in
Pulsed N2 in
Fig. 16-5  A schematic of the plasma skin regeneration hand
piece. Pulsed nitrogen gas is ionized by ultrahigh frequency (UHF)
energy inside the handpiece to form plasma. The plasma is directed
through the quartz nozzle at the tip, causing instantaneous heating
upon impact with the skin.
Microepidermal necrotic
debris (MEND)
Microthermal treatment
zone (MTZ)
Fig. 16-4  Fractional photothermolysis produces thousands of
treatment columns in the skin, called microscopic treatment zones
(MTZ). Collagen remodeling takes place in the MTZ in the weeks
after treatment. A small plug of melanin containing microepider­
mal necrotic debris (MEND) is responsible for the bronze-like
­appearance of the skin in the postoperative period. The MENDs will
shed as the skin underneath reepithelializes.

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Ablative and microablative skin resurfacing  •  Chapter 16
used in surgery for over a decade, the plasma has been used
primarily as conduction medium for electric current. With
PSR, the plasma itself produces controlled thermal damage
to the skin surface. The technology can be used at varying
­energies for different depths of effect, from superficial epider­
mal sloughing to deeper dermal heating.
The plasma skin regeneration device consists of an ­ultrahigh
frequency (UHF) radiofrequency generator which excites a
tuned resonator and imparts energy to a flow of inert nitrogen
gas within the handpiece. The activated, ionized gas is termed
plasma. Nitrogen is used for the gaseous source because it is
able to purge oxygen from the surface of the skin, minimiz­
ing the risk of unpredictable hot spots and charring. Upon
­formation, the plasma is directed through a quartz ­nozzle out
of the tip of the handpiece and onto the skin. The plasma
appears as a characteristic lilac glow which transitions to a yel­
lowish light called a Lewis-Raleigh afterglow (Fig. 16-6).
As the plasma hits the skin, energy is rapidly transferred to
the skin surface causing instantaneous heating in a ­controlled,
uniform manner, without an explosive effect on tissue or
epidermal removal. The depth and area of thermal effect
are ­ determined by the energy setting and spot size of the
­handpiece. The energy can be adjusted from 1 to 4 J per pulse.
The intended spot size of 6 mm is reached when the ­device
is held approximately 5 mm from the surface of the skin;
however, the thermal ­effect can be increased or decreased by
­defocusing the handpiece ­either closer or farther away from
the skin surface. High temperatures during each pulse erode
the tungsten resonator in the handpiece, so the handpiece
must be replaced after each use.
Studies
In all resurfacing techniques, the potential for improvement
is related to the depth and degree of the injury, regardless of
the method used.13 For properly selected patients, the clinical
results achieved after ablative resurfacing are excellent.
­However, the degree of improvement varies with the laser
­system used, number of passes, and operator skill.
Patients with fine wrinkling respond most dramatically to
both erbium and CO2 laser resurfacing (Fig. 16-7). Perior­
bital rhytides have been found to improve by 63–93% post-
treatment, and perioral rhytides have been found to improve
as much as 81–99% improvement.23–26 Patients with moderate
Fig. 16-6  Plasma appears as a characteristic lilac glow which
transitions to a yellowish light called a Lewis-Raleigh afterglow.
A
B
Fig. 16-7  Results 6 weeks after full-face CO2
laser resurfacing showing dramatic improve­
ment in photodamage, fine wrinkles, and skin
tightening; (A) before and (B) after.

230
Chapter 16
Cosmetic surgery procedures and techniques
to severe rhytides may achieve 45–50% or greater improve­
ment with the CO2 laser.27,28 Rhytides in areas of ­excessive
muscle activity such as the glabella and forehead tend not to
respond as well, but results may improve with the long-term
adjunctive use of botulinum toxin.
A pass with the Er:YAG laser immediately after CO2
­resurfacing removes a thin layer of thermally damaged tis­
sue and can reduce patient downtime. In a split-face com­
parison of combined CO2 and Er:YAG laser resurfacing and
CO2 resurfacing alone for the treatment of perioral rhytides,
the addition of the erbium laser immediately following CO2
­laser resurfacing reduced the duration of postoperative crust­
ing, swelling, and itching.29 There was no difference in clini­
cal ­result between the two sides, with a 70% improvement in
medium to deep rhytides after both techniques.29
CO2 resurfacing is also effective in the treatment of scar­
ring, though results are not as predictable as they are with the
treatment of rhytides. Elevated scars tend to improve more
than depressed scars and immature scars more than mature
scars.30,31 Mild, superficial, or atrophic acne scarring gen­
erally has good to excellent long-term results with 50–80%
­improvement.16,32–34 CO2 resurfacing for pitted acne scarring
is less effective, with 25–50% improvement.25,30,33
Long-term follow-up of patients who underwent combina­
tion carbon dioxide/erbium:YAG full-face laser resurfacing
for acne scarring or photodamage shows high patient satisfac­
tion.35 After 2.5 years, 75% of patients would recommend the
procedure, 71% would have the procedure done again, and
88% felt their appearance was improved. 35 Patients undergo­
ing laser resurfacing to treat acne scarring were as satisfied as
patients treated for photodamage. 35
Clinical results from Er:YAG resurfacing are generally not
as dramatic as those from CO2 laser resurfacing. Patients with
fine wrinkles and mild to modest photodamage have the best
results (Fig. 16-8). Those with mild to moderate wrinkling have
been shown to have about a 50% improvement in rhytides
­after Er:YAG resurfacing.17,34,36 Acne scars demonstrate about
a 50% improvement after Er:YAG resurfacing.37
A split-face comparison of variable pulse Er:YAG and CO2
resurfacing for the treatment of perioral rhytides confirmed
a shorter recovery period with the Er:YAG laser, but less
­dramatic results. The side treated with the CO2 laser showed
63% improvement with an average 7.7 days of crusting, while
the side treated with the variable pulse Er:YAG laser showed
48% improvement with an average 3.4 days of crusting.38
Since both fractional photothermolysis and plasma skin
regeneration are new techniques, few studies have been pub­
lished evaluating their results, optimal treatment parameters,
and long-term benefits and side effects. Preliminary studies
on fractional photothermolysis for the treatment of perior­
bital rhytides revealed mild improvement in 12% of patients,
­noticeable improvement in 30%, and moderate to significant
improvement in 54% 1 month after four treatments.11 Rokhsar
and Fitzpatrick treated 10 cases of ­ resistant melasma with
fractional photothermolysis at 6–12 mJ/MTZ with 2000–
3500 MTZ/cm2 at 1–2 week intervals. After four to six treat­
ment sessions, 60% of patients achieved 75–100% clearing
and 30% had less than 25% improvement (Fig. 16-9).39 Anec­
dotal evidence has demonstrated fractional ­photothermolysis
to be useful in the treatment of solar ­lentigines, overall skin
texture, and dilated pores following a series of three to five
treatment sessions. The device appears to work better on fine
to moderate rhytides than it does on deeper lines.40 Perioral
vertical rhytides are particularly resistant. As with other lower
recovery time procedures, rhytides are not improved to the
same degree as traditional ablative resurfacing.40
Fractional photothermolysis has also been studied in the
treatment of acne scars (Fig. 16-10). Roy Geronemus and
colleagues treated 17 subjects with ice-pick, boxcar, and roll­
ing-type acne scars with five treatments at 1–3-week intervals.
Mean improvement in acne scarring measured by typographic
imaging was found to be 22–62%.40
Pilot studies evaluating the use of a single, full-facial ­plasma
skin regeneration treatment at high energy (3–4 J) demonstrated
a mean improvement in overall facial rejuvenation of 50%
by 1 month.41 Potter and colleagues used silicone ­molding to
A
B
Fig. 16-8  Results 6 months after full-face short pulsed Er:YAG laser resurfacing for superficial early photoaging; (A) before and (B) after.
(Photos courtesy of Dr. Khalil Khatri.)

231
Ablative and microablative skin resurfacing  •  Chapter 16
demonstrate a 39% decrease in fine line depth 6 months after
one high-energy, full-face treatment.42
Bogle, Arndt, and Dover evaluated a series of three low-
energy plasma (1.2–1.8 J), full-face treatments for facial reju­
venation and found a 37% improvement in facial rhytides at
3 months’ follow-up.43 In the same study, participants rated
themselves as having a 68% improvement in overall facial
rejuvenation at 3 months’ follow-up (Fig. 16-11).43 Histo­
logic analysis of post-treatment samples revealed a decrease
in solar elastosis with significant new interdigitating collagen
and thickening of the collagen band at the dermal–­epidermal
junction.43 The mean depth of new collagen formation was
72.3 μm.43 Epidermal thickness was not changed by the
treatment.43
A
B
Fig. 16-10  Baseline (A) and one month
after (B) a series of Fraxel skin resurfacing
treatments for acne scaring. The patient has
acheived significant improvement.
A
B
Fig. 16-9  Baseline (A) and one month after
(B) a series of Fraxel skin resurfacing treat­
ments for the treatment of photoaging and
melasma showing improvement in rhytides,
pigmentation, and skin texture.

232
Chapter 16
Cosmetic surgery procedures and techniques
Discussion
As with any procedure, the treating physician must have a
complete understanding of the indications and limitations of
a given technique for cutaneous resurfacing. The CO2 laser
is a powerful tool that can have beneficial effects when used
properly for the correct indication. It can also have disastrous
consequences when used with nonstandard protocols, outside
the normal treatment areas, or in unskilled hands.44
CO2 resurfacing remains the gold standard for the ­treatment
of severely photodamaged skin. It can achieve ­ excellent
­clinical improvement of rhytides, textural anomalies, dyspig­
mentation, and atrophic scars. The downside to the procedure
is its extended reepithelialization period, prolonged erythema
that may persist for several months, and potential for delayed
permanent hypopigmentation.45,46 Post-treatment changes in
pigment and texture can be particularly noticeable adjacent
to nonresurfaced, sun-damaged skin. For this reason, it is pref­
erable to treat the entire face as a unit, rather than treating
single areas alone, such as the upper lip or periorbital area.
The major indications for carbon dioxide laser treatment are
the improvement of moderate to deep rhytides and atrophic
scars caused by acne, trauma, or surgery. Deep pitted or box-
car type acne scars may improve with full-face resurfacing;
however, most cases will require ancillary surgical ­procedures
such as excision or punch grafting for optimal results.
Other conditions that respond favorably to CO2 resur­
facing include rhinophyma, Favre-Racouchot, sebaceous
hyperplasia, xanthelasma, syringomas, actinic cheilitis, and
diffuse actinic keratoses.13 While dyschromias, such as solar
­lentigines, are greatly improved by laser resurfacing, they are
not regarded as a primary indication for this treatment.
Carbon dioxide resurfacing is limited mainly to the face.
Post-treatment skin regeneration relies upon the presence of
skin appendages to serve as sources of epithelium that can
migrate upward to form the new epidermis. The greater the
number of skin appendages per square centimeter of skin, the
more rapid the healing and the less risk for scarring. While
treatment of the hands, neck, and chest may be successful, a
much greater risk for scarring exists when treating non-facial
areas, and it is not recommended.13 A safer option would be
fractional resurfacing or a series of low-energy plasma rejuve­
nation treatments.
The ablative Er:YAG laser is best suited for the treatment of
mild-to-moderate rhytides, superficial pigmentation, atrophic
scars, and a variety of epidermal and dermal lesions, includ­
ing sebaceous hyperplasia, angiofibromas, adnexal tumors,
café-au-lait macules, and xanthelasma.15,17,47 Several studies
have documented its safe use in darker skin types.48,49 Mod­
erate photodamage and rhytides are better treated with the
variable-pulse Er:YAG laser; however, the improvement seen
is still not comparable to that of pulsed or scanned carbon
dioxide resurfacing, even when equal depths of ablation are
obtained.38
The addition of the ablative Er:YAG laser following
­carbon dioxide laser resurfacing may decrease the duration
of ­postoperative crusting and edema, presumably by reduc­
ing the amount of thermal necrosis induced by the carbon
dioxide laser.29 The additional Er:YAG pass ablates much of
the residual thermal damage caused by the carbon ­dioxide
laser. The removal of proinflammatory coagulated tissue
­results in less erythema and faster healing, and it does not ap­
pear to affect the clinical outcome or degree of new collagen
­formation.17,21,29,50
A
B
Fig. 16-11  Before (A) and after (B) a series
of three low-energy plasma skin regenera­
tion treatments spaced 3 weeks apart. The
patient has good improvement in fine rhytides,
pigmentation, and texture, as well as slight skin
tightening.

233
Ablative and microablative skin resurfacing  •  Chapter 16
Fractional photothermolysis can be used for the treatment
of photodamaged skin, facial rhytides, acne scars, surgical
scars, melasma, and photodamaged skin.40 Anecdotal evi­
dence suggests that it may be beneficial in the treatment of
striae distensae.51 Fractional laser resurfacing has the advan­
tage of ease of treatment with minimal downtime, and the
disadvantage of requiring multiple treatments for optimal re­
sults. An additional advantage is that it is safe and effective for
the treatment of non-facial areas such as the neck, chest, and
extremities.40
Indications for plasma skin regeneration include mild
to ­ severe rhytides, sun-damaged skin, acne scarring, and
­superficial benign skin lesions. Multiple low-energy treatments
appear to approximate the results of treatments at higher ener­
gies, with improvement in dyspigmentation, texture, and fine
lines.43 High-energy treatments may have better results in
terms of skin tightening, but will also have about 3–5 days
more recovery time.
Procedures and Techniques
Preoperative clinical considerations
Proper patient selection is essential to any cosmetic proce­
dure, including ablative resurfacing. During the initial con­
sultation, a complete medical and surgical history should be
obtained from the patient. It is particularly important to es­
tablish any contraindications to laser resurfacing including
isotretinoin use within 12 months of surgery, a tendency to­
ward keloid or hypertrophic scar formation, pregnancy, and
any condition which may cause reduced numbers of adnexal
structures such as scleroderma, burn scars, or history of ion­
izing radiation to the skin. Recent isotretinoin use appears
to alter the ability of epithelial cells in adnexal structures to
reepithelialize lasered skin, resulting in an increased risk of
keloid or hypertrophic scar formation.52 Previous laser re­
surfacing, dermabrasion, or deep chemical peels should also
be noted as they may slow the wound healing response as a
result of fibrosis. Patients with a prior history of transcuta­
neous lower blepharoplasty and limited infraorbital elastic­
ity may have increased risk of ectropion. Smokers should
be encouraged to quit or greatly reduce their habit before
and after surgery to reduce the risk of delayed or impaired
wound healing.
Equally important contraindications to ablative resurfacing
that the physician and clinical staff should watch for include
unrealistic patient expectations and a high probability of non­
compliance with postoperative care. The benefits, risks, and
limitations of the various types of ablative and microablative
resurfacing should be discussed with the patient in detail, in­
cluding a mention of alternative therapies so that the patient
can make an informed decision.
After a thorough review of the patient’s history and motiva­
tions, an examination of the proposed treatment area should
be performed with particular attention to skin type, texture,
rhytides, dyschromia, and pre-existing scarring. Patients desir­
ing periorbital treatment should be examined for scleral show,
lid lag, and ectropion. Active cutaneous bacterial or viral
infections in or near the treatment area should be completely
eradicated before the procedure.
Darker-skinned patients have the highest risk of postpro­
cedure hyperpigmentation. Some physicians choose to pre­
treat at-risk patients with topical retinoic acids, hydroquinone
bleaching agents, and alpha-hydroxy acids for several weeks
to reduce the risk of postoperative hyperpigmentation and
enhance wound healing.13 The usefulness of such regimens is
debatable, and studies have not shown them to have a signifi­
cant effect.53 Hydroquinone inhibits tyrosinase and decreases
melanosome formation, but it does not reach the deeper
melanocytes responsible for hyperpigmentation. Therefore,
treating hyperpigmentation if it appears after treatment is a
more effective approach.17,53
All patients should receive antiviral prophylaxis against
herpes infection before full-face or perioral resurfacing
because of the high prevalence of latent virus, even in persons
who have never been symptomatic. Trauma from thermal
damage can cause a reactivation of the herpes simplex virus
or predispose the patient to a primary infection during reepi­
thelialization.54 Effective regimens include famciclovir 250 mg
twice a day, acyclovir 400 mg three times a day, or valacyclovir
500 mg twice a day.55 Prophylaxis should begin 24 hours prior
to the procedure and continue for 7–10 days until reepitheli­
alization is complete.
Some surgeons routinely prescribe antibiotics for bacterial
prophylaxis; however, few data exist to support their use.56–58
Cephalexin, dicloxacillin, azithromycin, and ciprofloxacin all
have good coverage against cutaneous pathogens.13 Similar to
antiviral prophylaxis, antibiotic prophylaxis should begin 24
hours prior to the procedure and continue for 7–10 days
until reepithelialization is complete. Topical antibiotics are not
recommended postprocedure because of the risk of contact
dermatitis.13
Patients should avoid taking aspirin or other nonsteroidal
antiinflammatory medicines for at least 10 days prior to ­surgery
in an effort to decrease bleeding during the ­procedure.
Procedural techniques
Ablative resurfacing procedures can be quite uncomfortable
for the patient, depending on the device and energy used.
CO2 and Er:YAG resurfacing require significant analgesia,
and topical anesthetics are not sufficient. Combination oral
analgesia and topical anesthesia or intravenous conscious se­
dation combined with regional nerve blocks works extremely
well for these procedures. Intravenous sedation requires the
presence of an anesthesiologist, oxygen source, electrocardi­
ogram, blood pressure monitors, pulse oximeter, i.v. access,

234
Chapter 16
Cosmetic surgery procedures and techniques
and resuscitation cart. Propofol provides rapid sedation and is
­easily titrated. Midazolam may be used for initial sedation and
amnesia, with fentanyl used for primary analgesia.
Deep intravenous sedation or general anesthesia requires
no additional anesthesia. Less deep intravenous sedation is fre­
quently combined with regional anesthesia, including reg­ional
blocks of the supraorbital, supratrochlear, infraorbital, zygoma­
ticofacial, and mental nerves. The perimeter of the face should
be infiltrated as a field block, extending just past the treatment
border on the neck. Tissue infiltration with local anesthesia
should supplement the lateral forehead and temples, lateral
face, and upper eyelids. Care should be taken not to distort
existing wrinkles or scars due to excessive injection volume.
Topical anesthesia with a lipid-based anesthetic applied
45–90 minutes before the procedure appears to be sufficient
for fractional photothermolysis. Some patients may require
oral sedation, oral analgesia, or regional nerve blocks. Addi­
tional analgesia is obtained from forced air cooling with the
Zimmer device (Zimmer MedizinSysteme, Ulm, Germany) at
the time of treatment.
Low-energy plasma skin regeneration treatments can be eas­
ily performed under topical anesthesia with a variety of agents.
High-energy treatments are more uncomfortable and require
adjunctive oral sedation or pain medication. Particularly sen­
sitive areas such as the forehead and around the mouth may
require local infiltrative anesthesia or regional nerve blocks.
Carbon dioxide laser resurfacing
Before beginning the procedure, the treatment area and any
wrinkles or scars particularly bothersome to the patient should
be marked with a surgical pen. The patient’s hair should be
pinned out of the way and the hairline and eyebrows protected
with a petrolatum-based lubricant. Anesthetic drops are
placed in the eyes and antireflective, stainless steel eye shields
coated with sterile ophthalmic ointment to reduce corneal
abrasion are inserted.
Because the carbon dioxide laser light can easily cause a
fire, no flammable objects should be present in the laser field
including dry hair, dry gauze, and alcohol. It is also a good
idea to cover the periphery of the treatment area with wet
gauze. Likewise, supplemental nasal cannula oxygen must be
turned off while the laser is in use. A smoke evacuator should
be used to clear the vaporized tissue plume from the air and
reduce the risk of disease transmission.
Treatment parameters are set according to the type of laser,
the depth of the lesion, the treatment area, and the patient’s
skin type. The single-spot handpiece should be moved across
the skin at a slow enough rate to deliver single pulses with
minimal overlap. Pulse stacking leads to cumulative thermal
energy.59 The same principle applies to using the laser in the
computerized pattern generator (CPG) mode. Patterns should
be carefully aligned to avoid overlap at the edges.
The face should be treated in a systematic fashion, begin­
ning on the forehead and proceeding down the remainder of
the face. Deep rhytides should be stretched perpendicular to
their length to allow vaporization throughout the entire depth.
Eyelids are usually treated at lower pulse settings and densities
or with fewer passes. Care should be taken to avoid burning
the eyelashes and brows.
Feathering is performed to avoid sharp demarcation lines
between treated and untreated skin. Feathering can be accom­
plished by stopping the coverage area of subsequent passes
just short of the prior pass along the border with the neck and
by blending the treatment slightly into the hairline on the up­
per portion of the face. Feathering may also be accomplished
by treating the band of skin between the treated and untreated
areas at lower fluences.
Generally, the first laser pass results in removal of the epi­
dermis. The skin surface is covered with white, desiccated
­debris left after intracellular water vaporization. This debris is
gently wiped away with wet gauze before subsequent passes as
it can obstruct the beam from reaching the underlying dermis
and cause a build-up of thermal energy.60,61 The second laser
pass is performed in the same manner as the first. During the
first few passes, the tissue beneath the debris will appear pink
because of the intact papillary dermal plexus.
A third or subsequent pass can be applied to areas of
­particularly severe photodamage or scarring. The single-spot
handpiece is particularly useful for passing along the shoulder
edge or high points of acne scars. The end point of treatment
is when the target (e.g. wrinkle or scar) is clinically effaced,
when no further skin tightening is seen, or when a yellow dis­
coloration becomes apparent.32 The yellow/tan discoloration
(chamois appearance) of the tissue indicates that the upper
reticular dermis has been reached, and that an increasing
degree of thermal necrosis has been induced. Resurfacing
below this depth is not recommended because of the possibil­
ity of thermal damage to the adnexal structures from which
­reepithelialization occurs. In general, as the depth of penetra­
tion increases, the risk of textural changes, scarring, and per­
manent hypopigmentation increases.
Er:YAG laser resurfacing
The preparation for Er:YAG resurfacing is similar to that
of CO2 resurfacing. The treatment area should be marked,
flammable objects should be removed from the field, and
antireflective, stainless steel eye shields should be placed in the
patient’s eyes. Hair may be pinned out of the way and the
hairline and eyebrows protected with a petrolatum-based lu­
bricant. Because the Er:YAG laser has a very high coefficient
of absorption for water, it is important that the operative field
remain dry. Moisture on the surface of the skin from water or
blood will decrease the effect of the laser and increase super­
ficial ablation.
The short-pulsed Er:YAG laser can be set at various spot
sizes and fluences, depending on the device being used and
the indication for treatment. Common parameters are a spot
size of 3–7 mm and an energy of 12 J. Lower fluences (5 J/cm2
per pass) are used to treat delicate areas such as around
the eyes and in the treatment of superficial lesions. Higher

235
Ablative and microablative skin resurfacing  •  Chapter 16
fluences (12–15 J/cm2 per pass) are indicated with severely
­photodamaged skin or significant acne scarring. Fluences less
than 5 J/cm2 heat the target too slowly, leading to collateral
damage of the surrounding tissues from heat transference.21
Because of the small spot size, it is helpful to divide the
treatment area into smaller zones for even coverage. Treat­
ments are performed by passing the laser over a zone in a
paintbrush fashion with approximately 50% overlap. A com­
puterized scanner can simplify the process, making it more
even and consistent. Subsequent passes should be oriented at
different directions to avoid striping. Wiping between passes is
not necessary.
Roughly three passes are required to produce total epider­
mal ablation, depending on the energy and spot size.20 Pin­
point bleeding indicates penetration into the papillary dermis
and serves as a useful end point to avoid overpenetration.17,21
Care should be taken if epinephrine is used with the local
anesthetic, as pinpoint bleeding may not be perceptible. Per­
forming fewer passes at the periphery will feather the treat­
ment and minimize the risk of a demarcation line between
treated and untreated skin.
With a variable-pulsed Er:YAG laser such as the Contour
(Sciton, Palo Alto, CA), common parameters for laser skin re­
surfacing are 90 μm ablation (22.5 J/cm2) and 50 μm coagu­
lation.62 A scanning handpiece with 50% overlap is used to
vaporize the epidermis in a single pass over the entire face.
Additional one or two regional passes are then delivered using
identical laser settings to treat any residual rhytides or scars.
Laser scans are placed adjacent to one another without over­
lapping to prevent char formation. Partially desiccated debris
need not be removed between passes, as this tissue absorbs,
and can be vaporized by, the Er:YAG laser. The skin under­
neath should be pink with minimal bleeding.
Fractional photothermolysis
To prepare a patient for fractional photothermolysis with the
Fraxel laser (Reliant Technologies, Mountain View, CA), the
skin should be washed with cleanser and prepped with alco­
hol. A lipid-based topical anesthetic (e.g. 1% lidocaine/4%
tetracaine) is then applied for 45 minutes to 1 hour. Before
laser treatment, the anesthetic is removed and a water-soluble
blue dye (OptiGuide™ Blue, Reliant Technologies, Mountain
View, CA) is applied in a thin layer to allow the laser’s ­optical
tracking system to detect contact with the skin and adjust the
pattern of microscopic treatment columns with respect to
hand velocity.
Another layer of either topical anesthetic ointment or pet­
rolatum-based ointment is applied to help the handpiece glide
along the skin’s surface. Once the 15 mm handpiece comes
into contact with the skin, it should be moved in a straight line
consisting of one stroke until the end of the cosmetic unit is
reached. The handpiece should then be retraced back over
the same row to return to the starting point, completing two
passes. Concomitant forced air cooling with the Zimmer
­device is useful to prevent bulk heating and achieve a greater
degree of analgesia.
The handpiece tip has markings that help guide the posi­
tion of successive passes (Fig. 16-12). The first stroke of the
third pass should be positioned either by overlapping the
prior pass by 50% or with no overlap. Again, when the end
of the cosmetic unit is reached, the handpiece should be re­
traced back over the same row. A 7 mm tip is available for use
in the treatment of small areas such as the nasal bridge or
periocular skin.
After a cosmetic unit has been treated entirely with over­
lapping strokes from side to side, the direction of the rows
should change by 90 degrees, and the process repeated from
top to bottom. Each square centimeter of skin should end up
with eight passes. Thus, if the laser was set at 250 MTZ/cm2,
the end treatment density would be 2000 MTZ/cm2 with
• The CO2 and Er:YAG lasers target both
­intracellular and extracellular water based on the
principles of selective photothermolysis.
• The Er:YAG laser has more precise ­tissue
­ablation and a relatively small zone of
­residual thermal damage, resulting in faster
­reepithelialization and an improved side effect
profile in comparison to the CO2 laser, but less
dramatic clinical results.
• A pass with the Er:YAG laser immediately
­following CO2 resurfacing speeds healing and
reduces the duration of postoperative crusting,
swelling, and itching, but does not add to the
clinical result.
• Variable-pulse Er:YAG lasers can be used in a
short-pulse mode for tissue ablation and a long-
pulse mode for thermal damage and collagen
contraction. They have better tissue ­penetration
and deeper zones of thermal necrosis than
­traditional short-pulsed devices.
Pearls
• CO2 resurfacing should be limited to the face.
A high incidence of unacceptable scarring and
fibrosis occurs when treating non-facial areas.
• It is preferable to treat the entire face as a unit,
rather than treating single areas alone, as
post-treatment changes in pigment and ­texture
can be particularly noticeable adjacent to
­nonresurfaced, sun-damaged skin.
• Rhytides in areas of excessive muscle ­activity
such as the glabella and forehead tend to
recur soon after laser resurfacing. Results are
improved with the long-term adjunctive use of
botulinum toxin.
• Resurfacing depth should be limited to the
­upper reticular or papillary dermis to reduce the
risk of delayed hypopigmentation and scarring.
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Cosmetic surgery procedures and techniques
­approximately 5–8 kJ of energy delivered over a full-face
­treatment. When the 50% overlap technique is used, the edges
of the treatment area will receive fewer passes because of the
stroke pattern, providing a built-in feathering effect.
Treatment parameters can be adjusted according to the de­
sired depth of injury. The energy setting controls the depth of
injury, while the density setting controls the percentage of skin
that is treated.40 Thus, for the treatment of superficial targets
such as pigment, a typical course might consist of three to
five treatments at low energies (8–10 mJ) and higher densities
(2000–3000 MTZ/cm2) spaced 2–4 weeks apart. For the treat­
ment of deeper lesions such as acne scars, a typical course
might consist of four to six treatments at higher energies (16–
20 mJ) and lower densities (1000–1500 MTZ/cm2) spaced 2–4
weeks apart.
With the second-generation Fraxel device, energy set­
tings can be significantly increased, as can the density of laser
pulses delivered. For acne scarring or deeper photoaging,
­energies of up to 70 mJ may be used. Typical density patterns
are at a setting of six to eight (to roughly be equivalent to the
2000 MTZ/cm2 with the original Fraxel device). Eight passes
are used as with the original Fraxel device. Software updates
to the optical tracking system and contact motion sensors
have eliminated the need for application of a blue contrast
agent.
Treatments with the fractional Er:YAG lasers (1540 nm
Fractional Er:YAG, Palomar Medical Technologies Inc.,
­Burlington, MA and 1440 nm YAG laser, Affirm, Cynosure
Inc., Westford, MA) have been more recently described. The
use of each appears to be somewhat less involved than Fraxel
treatments. Optical tracking is avoided, so the need for a
skin colorant applied before the procedure is eliminated. In
­addition, topical anesthesia is only occasionally required, with
the procedures being approximately half as uncomfortable as
the Fraxel laser resurfacing treatment.
Plasma skin regeneration
Patients undergoing plasma skin regeneration should arrive
at least an hour beforehand so that a topical anesthetic cream
can be applied to the treatment area. Patients undergoing
high-energy treatments will require adjunctive oral analgesia
and/or sedation.
Generally, it is a good idea to work in aesthetic segments of
the face (i.e. forehead, nose, cheek, chin, etc.), removing the an­
esthetic cream for each area immediately before treating that
area rather than removing the cream for the entire face at once.
Hydration of the epidermis has been found to ­influence the
amount of energy absorbed, so the physician should develop
a protocol to standardize the delay time between ­removal of
topical anesthesia and starting the procedure.63
• Early clinical evidence reveals fractional resur­
facing to be particularly useful in the treatment
of photoaging, mild to moderate rhytides, acne
scarring, and superficial pigmentary disorders
including melasma.
• The device is safe for treatment of non-facial
­areas such as the neck, chest, back, and
­extremities.
• Forced air cooling is useful during the treatment
to prevent bulk heating and achieve a greater
degree of analgesia.
• The energy setting controls the depth of injury,
while the density setting controls the percentage
of skin that is treated. Higher-energy settings
thus have a greater effect in the ­treatment
of rhytides and scarring, while low-energy
­settings are sufficient for superficial pigmentary
­disorders.
Pearls
A
B
Fig. 16-12  (A) Tips for the fractional photothermolysis device
come in 2 sizes: 15 mm and 7 mm. (B) Roller type which eliminates
the need to use blue dye.
• Avoid scrubbing and harsh cleansers
­postprocedure. This can cause excessive
­erythema, erosions, and scarring.
• Careful attention should be paid to the
­positioning of treatment rows to avoid
­unnecessary heat build-up.
• The handpiece should glide lightly over the skin.
Too much pressure during a pass can cause
abrasions or excessive erythema on fragile skin.
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237
Ablative and microablative skin resurfacing  •  Chapter 16
Topical anesthetic should be gently wiped off the segment
to be treated with dry gauze. It is not necessary to use water-
or alcohol-soaked gauze as this will change the hydration
properties of the skin. Once a facial segment is ready for treat­
ment, the tip of the handpiece should be held approximately
5 mm from the skin’s surface (Fig. 16-13). The pulses are de­
livered in a paintbrush fashion in rows of one direction (either
all right to left or all left to right) because a zig-zag pattern has
been found to cause heat build-up at the corners where one
changes direction. Pulses should not be overlapped more than
about 10%. Wet gauze should be placed over the patient’s
eyes, brows, and hairline when working in adjacent areas.
There are three recommended treatment guidelines,
termed PSR1, PSR2, and PSR3. The PSR1 protocol uses a
series of low-energy treatments spaced 3 weeks apart. The
first treatment is performed at 1.0–1.2 J, and energies are
increased as tolerated at subsequent visits. Recovery time is
3–4 days. The PSR1 protocol is a good choice for those with
mild to moderate photodamage or those who cannot tolerate
more than a few days of healing time. The PSR2 protocol
uses one high-energy pass (3.0–4.0 J) with a recovery time of
5–7 days, and the PSR3 protocol uses two high-energy passes
(3.0–4.0 J) with a recovery time of 6–10 days. The PSR2 pro­
tocol is a good choice for those with moderate photodamage,
while the PSR3 protocol is a good choice for those with mod­
erate to severe photodamage and those who desire a greater
degree of skin tightening. A series of treatments in the mid-
energy group (1.5–3.0 J) has good results in improving skin
texture and discoloration, but has only slightly less recovery
time than a single high-energy treatment.43 Thus, most prac­
titioners prefer to use the suggested PSR1, 2, or 3 protocols.
To avoid lines of demarcation with the high-energy proto­
cols, the borders of the treatment area should be feathered by
increasing the distance of the nozzle from the surface of the
skin to about 1 cm. Feathering can also be achieved by holding
the handpiece nozzle at an angle with respect to the skin
surface or reducing the power setting. There is no need for
­feathering in the low-energy PSR1 protocol.
Postoperative clinical ­considerations
Postoperative care after ablative and microablative resurfac­
ing ranges from highly demanding to minimal, depending on
the device. Recovery after CO2 and Er:YAG laser resurfacing
is probably the most challenging as it involves a high degree of
patient compliance for up to several weeks, depending on the
depth of thermal injury. Patients must be closely monitored
with frequent follow-up visits to detect complications, aid in
wound care, and provide emotional support during the heal­
ing process (Fig. 16-14).
There are generally two schools of thought regard-
ing wound care after ablative resurfacing. The closed pro­
tocol ­ attempts to take advantage of the idea that wounds
heal more quickly in a moist environment. A semiocclusive
dressing is placed on the denuded skin immediately post-
­treatment (Fig. 16-15). These dressings include polyurethane
films, ­ hydrocolloids, and ­ hydrogels, and have been shown
to accelerate the rate of reepithelialization and decrease
postoperative pain.64–66 The open wound care protocol uses
frequent soaks and copious amounts of bland ointment to
diminish crust formation and promote reepithelialization.
Topical antibiotics should not be used because of the
­increased risk of contact dermatitis. Comparison of healing
• Plasma skin regeneration technology can be
used at varying energies for different depths
of effect, from superficial epidermal sloughing
to deeper dermal heating.
• Three low-energy treatments can give similar
results to one high-energy treatment in terms of
fine lines, dyspigmentation, and overall texture
with less recovery time. High-energy treatments
are preferred for the improvement of deep
rhytides and skin tightening.
• Double-passing over deep scars or wrinkles can
give additional benefit and improve results with
single-pass full-face treatments.
• A series of low-energy treatments can improve
pigmentation and textural irregularities on the
neck, chest, and hands.
Pearls
Fig. 16-13  Low-energy treatment with plasma skin regeneration. The
handpiece is held approximately 5 mm from the skin surface. There
is no char formation and the epidermis is left intact postprocedure.
• Mid-energy (1.6–3.0 J) treatments do not offer
significantly better improvement than low-energy
treatments, but have several days more recovery
time. For this reason, most physicians prefer the
use of low- or high-energy protocols.
• Treatments should be performed in rows all right
to left or left to right. Alternating, or zig-zagging,
directions can cause excessive heat build-up at
the corners.
• Energy settings above 3 J should not be
used in the infraorbital area to avoid ectropion
formation.
Pitfalls

238
Chapter 16
Cosmetic surgery procedures and techniques
with a silicone occlusive dressing versus open wound care (soaks
and ointment application) after CO2 and Er:YAG skin resur­
facing found the occlusive ­dressing to decrease the severity and
duration of post-laser erythema, swelling, and crusting.67,68
With either protocol, patients should continue oral antibi­
otics and antiviral medications for 7–10 days until reepithe­
lialization is complete. Oral anxiolytics such as lorazepam
or diazepam are helpful to relieve anxiety and improve
sleep ­ patterns. Antipruritic agents such as hydroxyzine are
­prescribed as needed.
Patients should be instructed not to pick or rub their ­fragile
skin and to avoid sun exposure. Makeup can usually be ­applied
in 7–10 days when reepithelialization is complete.
Expected adverse effects of traditional ablative laser resur­
facing include transient erythema, edema, serous discharge,
crusting, discomfort, and pruritus (Fig. 16-16A).44,46 Most of
these will resolve as the skin reepithelializes. Milia, acne, and
perioral dermatitis are common due to occlusion from heavy
ointments or occlusive dressings.46 Milia can be treated with
gentle extraction after the skin has healed, and acneiform
A
B
C
D
Fig. 16-14  (A) A patient with moderate
photoaging before treatment with the CO2
laser. (B) Three days after laser resurfacing the
patient has prominent erythema, swelling, and
oozing. (C) Ten days after laser resurfacing
the erythema and swelling have dramatically
decreased. (D) Very good improvement in
photodamage 6 weeks after laser treatment.

239
Ablative and microablative skin resurfacing  •  Chapter 16
­lesions can be treated with topical acne medications or a
short course of oral antibiotics.
Hyperpigmentation is common after ablative resurfacing
procedures, although it is usually transient and responds well
to treatment with topical retinoic acid, hydroquinone, or a
series of light chemical peels (Fig. 16-16B).17,44,62 ­Permanent
­hypopigmentation, appearing weeks to months postpro­
cedure, was originally reported in up to 20% of patients
after CO2 laser resurfacing. Its incidence is correlated to
­increased ­resurfacing depths and resultant thermal injury to ­
melanocytes (Fig. 16-16C).45,69 The risk of this complica­
tion is very low when CO2 laser resurfacing is performed
judiciously.
Two to ten percent of patients experience a reactivation
of labial herpes simplex virus infection, usually 5–10 days
­after the procedure, even with appropriate prophylaxis.54 The
­outbreak may present as a cluster of erosions rather than vesi­
cles because of the deepithelialized skin. Treatment with oral
antivirals is usually effective.55 Approximately 4% of patients
develop superficial bacterial or yeast infections 2–10 days
postprocedure. The typical presentation is a papulopustular
eruption with pain or itching, but infection can also present
as maceration or necrotic tissue. Any suspect area should be
­cultured immediately and empiric therapy should be started to
prevent dissemination and scarring. The most common path­
ogens are Staphylococcus, Pseudomonas, and Candida species.13
Development of scars after laser resurfacing can be caused
by excessive resurfacing depth, infection, and poor postopera­
tive wound care (Fig. 16-16D). Hypertrophic scarring is seen
most often in non-facial skin resurfacing. Other areas that are
prone to scarring are the chin, mandible, neck, and perioral
region.17 Scarring and fibrosis of the cheek or lower eyelid
can lead to ectropion formation. Localized areas of persist­
ent erythema may be evolving hypertrophic scars. Early treat­
ment including high-potency topical or intralesional steroids,
silicone sheeting, and the pulsed dye laser can offer significant
improvement.
Recovery time after fractional laser resurfacing is minimal
in comparison to traditional ablative resurfacing lasers. Red­
ness lasts an average of 3 to 5 days. Swelling is less ­common
and when present may lasts 1–5 days. Immediately after treat­
ment, the blue dye is gently washed off with a mild soap.
Harsh scrubbing may result in abrasions or excessive ery­
thema. Small amounts of the dye may remain in the pores
for several days (Fig. 16-17). Discomfort is generally mild,
similar to a sunburn, and easily relieved by cool compresses or
­acetaminophen. Elevation of the treated area on the evening
of treatment will help keep edema to a minimum.
Within the first few days after treatment, the skin may
develop a bronzed appearance due to the presence of mela­
nin-containing microepidermal necrotic debris (MENDS).
MENDS form beneath the intact stratum corneum in each
MTZ and gradually slough off within the first week. Other
than the application of a light moisturizer, postoperative skin
care is generally not required and most patients can return to
normal activities in 2–3 days.
Immediate and short-term side effects of fractional photo­
thermolysis in patients undergoing treatment on the face,
neck, chest, and hands include transient post-treatment ery­
thema (100%), xerosis (87%), facial edema (82%), ­ flaking
(60%), superficial scratches (47%), pruritus (37%), and
bronzing (27%).70 Reactivation of herpes simplex virus can
A
B
Fig. 16-15  (A) Occlusive silon TSR
dressing applied immediately after CO2
laser resurfacing. (B) Same patient with gauze
and a flexinet dressing applied over the silon
TSR biologic skin dressing.

240
Chapter 16
Cosmetic surgery procedures and techniques
occasionally be seen and may require prophylaxis in at-risk
­patients.70 Mild blistering of the skin may occur at higher
treatment densities (over 2000 MTZ/cm2), especially around
the chin and temple, as a result of bulk heating. Blistering
should be treated with appropriate wound care and frequent
application of a bland ointment. Long-term adverse events
including hypopigmentation and scarring have not been
­reported.40
The new fractional deep dermal ablation (FDDA) device
has resulted in significant tissue tightening and rejuvenation
of the skin. Currently, studies are ongoing with regard to its
potential to improve acne scarring.
Recovery after plasma skin resurfacing is unique because
the desiccated outer layer of skin is left intact to act as a
­‘biologic’ dressing, virtually eliminating oozing or crust forma­
tion. Immediately after treatment, a thin layer of bland oint­
ment is applied, and cool compresses are used to minimize
swelling. Patients should be instructed to avoid sun exposure
and apply a bland ointment to the face at frequent intervals
while the skin is healing.
Low-energy PSR1 treatments may cause only erythema
for 2–3 days. High-energy treatments generally have greater
erythema and the skin develops a ‘dirty’ look as the damaged
epidermis and upper dermis slough off. This resolves in 5–10
days. Patients should be instructed not to pick at the peeling
skin as it can cause prolonged erythema or scarring.
There have been no major side effects associated with
plasma skin regeneration in studies to date.41,43 As in all
A
C
B
D
Fig. 16-16  Side effects after laser resurfacing. (A) Residual erythema 6 weeks after CO2 resurfacing. (B) Transient patchy hyperpigmentation
6 weeks after CO2 resurfacing. (C) Subtle hypopigmentation 6 months following CO2 resurfacing. (D) Extensive hypertrophic scarring 1 year
after CO2 resurfacing of the face and neck.

241
Ablative and microablative skin resurfacing  •  Chapter 16
­procedures utilizing heat energy, possible side effects include
erythema, edema, epidermal deepithelialization, and post-
treatment hyperpigmentation. Erythema and edema are
common postprocedure, usually resolving in several days.
Edema can be decreased by the application of cool com­
presses postprocedure. Epidermal deepithelialization is a
risk at higher energies and should be treated with appropri­
ate wound care and liberal application of a bland ointment.
Temporary ­hyperpigmentation has been reported at mid- to
high-energy treatments.43 There have been no reported in­
stances of scarring, infection, or hypopigmentation in clinical
trials to date.
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keratinocyte proliferation. J Trauma 1989; 29:924–930.
68. Batra RS, Ort RJ, Jacob C, et al. Evaluation of a silicone occlusive
dressing after laser skin resurfacing. Arch Dermatol 2001; 137:
1317–1321.
69. Jeong JT, Kye YC. Resurfacing of pitted facial acne scars with a long-
pulsed Er:YAG laser. Dermatol Surg 2001; 27:107–110.
70. Fisher GH, Geronemus RG. Short-term side effects of fractional
photothermolysis. Dermatol Surg 2005; 31:1245–1249.

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Appendix A
Laser Skin Resurfacing Consent Form
Carbon dioxide (CO2) and Erbium:YAG lasers have been used for the treatment of various conditions over the past 25 years
and for skin resurfacing since 1994. These lasers generate an infrared beam, which heats and vaporizes skin tissue layer-by-layer.
These lasers are best suited for superficial skin conditions such as fine lines and moderately deep wrinkles, mottled pigmentation,
keratoses (pre-cancers), and mild acne scarring.
Patients who undergo treatment of limited areas usually receive local anesthesia with or without an oral sedative. Patients who
undergo treatment of the full face will require either general anesthesia or intravenous sedation in addition to local anesthesia.
After the treatment, a precise wound is produced, which will heal in 1 to 2 weeks. Swelling, oozing and crusting are expected
­during the first 3 days. Redness will occur in the treatment area and usually resolves in 4 to 12 weeks.
Risks associated with this laser treatment include, but are not limited to:
1.  Infection (bacterial, viral ‘cold sores,’ or yeast)
2.  Dyspigmentation (skin lightening or darkening)
3.  Demarcation lines or patches
4.  Persistent facial redness
5.  Skin depression or scarring
6.  Incomplete removal of damaged skin, scars or wrinkles
7.  Flaring of acne
8.  Dermatitis or skin irritation
To minimize the chances of side effects and complications, it is important that you follow all postoperative instructions
carefully.
The procedure for treating my condition, the potential risks and benefits of the procedure, the likely results without such treat­
ment, and the available alternatives have been fully explained to me. While rare, unexpected risks or complications not discussed
may occur, and there is no guarantee that this procedure will improve my condition. I request performance of the procedure
described above and agree to have photographs taken. These photographs will be used for educational purposes and may be used
for publication.
______________________________________ 
______________________________
Patient Name - PRINT 
Date
______________________________________
Patient Signature
I have explained the above statements to the patient
and answered all questions.
______________________________________ 
______________________________
Physician Signature 
Date
Appendix B
Laser Skin Resurfacing Patient Information Sheet
Carbon dioxide (CO2) and Erbium:YAG lasers can be used to treat facial wrinkles, scars, and other textural irregularities. These
lasers allow gentle, layer-by-layer removal of skin. Wrinkles and scars that have the most favorable response are sharply defined
and shallow. The procedure is done on an outpatient basis and may take 30 minutes to 2 hours depending upon the extent of
treatment.
Pretreatment
During your initial consultation, we will evaluate your medical history and examine your skin to determine if laser resurfacing is
appropriate for you. The procedure will be explained in detail. You may be given a prescription for creams that should be used
nightly for at least two weeks prior to the procedure as well as prophylactic antibacterial and antiviral medications. Aspirin and

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Cosmetic surgery procedures and techniques
Appendix C
Fractional Photothermolysis Consent Form
The fractional resurfacing laser uses an erbium fiber laser that targets water in the skin. The beam creates thousands of tiny wounds
with normal skin surrounding. Because this is done microscopically, the wound is not visible and healing time is minimized. Each
session treats about 20% of the skin surface, so four to six treatments are needed to theoretically treat the entire surface.
The fractional laser is used to treat photoaging, sun-induced brown spots, wrinkling, and melasma. The treatment area will be
anesthetized with a topical numbing cream, but you may still feel a stinging or burning discomfort during and shortly after the
procedure. Following your treatment you may experience swelling and redness for several days to 1 week. Dryness, light peeling
and a bronzed appearance of the skin may also occur.
Improvement is progressive, and more than one treatment is required to achieve desired results. The number and spacing of
treatments varies by the individual and the condition being treated, but most patients undergo four to five treatments.
Risks associated with this laser treatment include, but are not limited to:
1.  Redness in the treatment area
2.  Swelling
3.  Dyspigmentation (skin lightening or darkening)
4.  Pinpoint bleeding
5.  Blisters or scabbing
6.  Infection (Bacterial, viral ‘cold sores,’ or yeast)
7.  Scarring
To minimize the chances of side effects and complications, it is important that you follow all postoperative instructions
carefully.
The procedure for treating my condition, the potential risks and benefits of the procedure, the likely results without such
treatment, and the available alternatives have been fully explained to me. While rare, unexpected risks or complications not
discussed may occur, and there is no guarantee that this procedure will improve my condition. I request performance of the pro­
cedure described above and agree to have photographs taken. These photographs will be used for educational purposes and may
be used for publication.
aspirin-like products (i.e. Motrin, Advil, Aleve, Nuprin) should be avoided for one week prior to surgery. You should plan for an
escort to accompany you to the procedure as you will not be able to drive yourself home.
The procedure
Photographs will be taken of the treatment area. The area(s) to be treated will be injected with a local anesthetic. If you are having
intravenous sedation (‘Twilight Sleep’) medication to make you sleepy will be given to you in a vein by an anesthesiologist. The
treatment will be performed by your physician using the CO2 and/or erbium laser. After the procedure, dressings are applied, and
you will be given detailed postoperative instructions including wound care. Do not plan on returning to work for approximately
14 days following your procedure.
Postoperative care
Immediately after the procedure, the treatment area will appear pink or red (as if scraped or abraded), swollen, and will drain
clear-colored fluid. If no dressing has been applied, you will need to wash the area every several hours with a gentle cleanser
(unscented Dove, Basis, or Purpose) and apply Aquaphor Healing Ointment every few hours to keep the area moist. If a dressing
has been applied it will be removed in 2 to 3 days. Swelling clears within several days, and oozing clears in 1 to 2 weeks. The pink
color fades within 6 weeks, although it may persist for up to 3 months. Drinking fluids, getting as much rest as possible, and taking
your prescribed medications are important factors in your healing process. Makeup and your usual facial care products should
not be applied until the area is healed.
Sun protection is imperative during the immediate postoperative period. We will arrange to see you for a follow-up appoint­
ment within 1 to 3 days, later that week, and again 3 to 6 weeks later.

245
Ablative and microablative skin resurfacing  •  Chapter 16
______________________________________ 
_____________________________
Patient Name - PRINT 
Date
______________________________________
Patient Signature
I have explained the above statements to the patient
and answered all questions.
______________________________________ 
_____________________________
Physician Signature 
Date
Appendix D
Fractional Photothermolysis Patient ­Information Sheet
Fractional photothermolysis is effective in the treatment of photodamaged skin, wrinkles, acne scars, surgical scars, and melasma.
Unlike traditional laser resurfacing it is safe for the treatment of non-facial areas such as the neck, chest, back, and hands. Sun-
induced brown spots, fine wrinkles and scars, and overall skin texture have the most favorable response. A series of four to six or
more treatments is recommended.
Pretreatment
During your initial consultation, we will evaluate your medical history and examine your skin to determine if fractional resurfac­
ing is appropriate for you. The procedure will be explained in detail. You may be given a prescription to prevent cold sores. Topical
retinoids should be discontinued 1 week before treatment.
The procedure
When you arrive, a topical anesthetic will be applied to your skin for about 1 hour. You may wish to bring something to read to
pass the time. A blue dye that helps the laser handpiece recognize the skin will be applied prior to the procedure. The procedure
is uncomfortable, and you will experience a burning or stinging sensation. The anesthetic will make the procedure tolerable, and
chilled air will be applied during the treatment to make the procedure more comfortable. Treatments take 20 to 40 minutes,
­depending on the extent of area treated.
Postoperative care
Immediately after the procedure, the blue dye will be removed with a gentle cleanser. Some blue discoloration is usually left in
the pores or deeper wrinkles. It is important not to scrub it off, but to let it come off on its own over the next day or two. You will
experience a sunburn-like sensation for about an hour, then virtually no discomfort. Cool compresses will help relieve stinging or
burning. Your skin will have a pink-red tone for 4 to 7 days following the procedure. This normally evolves into a bronze-like ap­
pearance which can last for 1 to 2 weeks. Swelling varies from person to person and generally resolves in 2 to 3 days. Itching and
dryness are common symptoms once the skin has healed initially. Flakiness and dry crusting will gradually clear. Use only bland
moisturizers that cause no irritation. Makeup can be applied the next day and sun protection is imperative. Most patients are able
to return to work or normal activities after 2 to 3 days.

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Appendix E
Plasma Skin Regeneration Consent Form
Plasma skin regeneration uses nitrogen plasma energy to heat the superficial layers of the skin, resulting in tissue remodeling and
new collagen growth. The treatment is used to improve photoaging, dyspigmentation, scars, wrinkles, and sagging. Plasma skin
regeneration can be performed at varying energies for different depths of effect, from superficial epidermal effects similar to a light
chemical peel to deeper dermal heating for the improvement of more extensive photodamage or scarring. Low-energy treatments
have 3 to 5 days of recovery time while high-energy treatments may require a week or more of healing.
Low-energy treatments require only topical numbing cream, while high-energy treatments require oral pain medications and
local anesthesia. Following your treatment you may experience swelling and redness for several days to 1 week. Light peeling of
damaged skin occurs as the new skin forms underneath.
Improvement from low-energy treatments is progressive, requiring multiple sessions to achieve desired results. High-energy
treatments are performed in a single session.
Risks associated with plasma regeneration include, but are not limited to:
1.  Redness in the treatment area
2.  Swelling
3.  Dyspigmentation (skin lightening or darkening)
4.  Blisters or scabbing
5.  Infection (Bacterial, viral ‘cold sores,’ or yeast)
6.  Scarring
To minimize the chances of side effects and complications, it is important that you follow all postoperative instructions
carefully.
The procedure for treating my condition, the potential risks and benefits of the procedure, the likely results without such treat­
ment, and the available alternatives have been fully explained to me. While rare, unexpected risks or complications not discussed
may occur, and there is no guarantee that this procedure will improve my condition. I request performance of the procedure
described above and agree to have photographs taken. These photographs will be used for educational purposes and may be used
for publication.
______________________________________ 
______________________________
Patient Name - PRINT 
Date
______________________________________
Patient Signature
I have explained the above statements to the patient
and answered all questions.
______________________________________ 
______________________________
Physician Signature 
Date
Appendix F
Plasma Skin Regeneration Patient Information Sheet
Plasma skin regeneration is used to improve photoaging, mottled pigmentation, scars, and wrinkles. It can be performed at varying
energies for different depths of effect. Low-energy treatments are performed in a series of three to four treatments spaced 3 weeks
apart to achieve more superficial improvement. High-energy treatments are performed in a single session and indicated for more
severe sun damage, deeper wrinkles, and scarring.
Pretreatment
During your initial consultation, we will evaluate your medical history and examine your skin to determine if plasma skin regen­
eration is appropriate for you. The procedure will be explained in detail. You may be given a prescription to prevent cold sores.
Topical retinoids (Retin-A, Renova, Differin, Avage, Tazorac) should be discontinued 1 week beforehand. If you are scheduled
for a high-energy treatment, you will be given one or more medications to make you more comfortable during the procedure. You
should plan for an escort to accompany you to the procedure as you will not be able to drive yourself home.

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Ablative and microablative skin resurfacing  •  Chapter 16
The procedure
When you arrive, a topical anesthetic will be applied to your skin for about 1 hour. You may wish to bring something to read to
pass the time. Patients undergoing high-energy treatments will also receive oral pain medication and injection of local anesthetic
in or around the treatment area. During the procedure, you may experience a burning or heat sensation. Treatments take 20 to
40 minutes.
Postoperative care
Immediately after the procedure, we will apply a bland ointment to your treated skin. Cool compresses will help relieve discomfort
and decrease swelling. When you arrive home, you will need to apply Aquaphor Healing Ointment to the skin at frequent intervals
during the day. Your skin will have a pink-red tone for 2 to 7 days. A ‘dirty’ brown discoloration is usually present which represents
the old, damaged skin and serves as a natural dressing. This will gradually flake and peel off as the skin heals underneath. You
must avoid picking your skin or trying to remove the brown flakes as this can cause prolonged redness, open sores, and the poten­
tial of scarring. Swelling varies from person to person and generally resolves in 2 to 4 days. Sun protection is important while the
skin is healing. Most patients are able to return to work or normal activities 2 to 3 days after low-energy procedures and about a
week after high-energy procedures.

History and Science
Photodynamic therapy (PDT) has evolved over the past
­century into an effective and practical cutaneous therapeutic
modality. The application of topical photosensitizers, namely
5-aminolevulinic acid (ALA), for short incubation times com­
bined with newer laser and light sources is safe and useful for
a variety of skin conditions and has minimal side effects. PDT
with ALA and blue light, long-pulsed pulsed dye laser (LP
PDL) or intense pulsed light sources (IPL) is used for ­treatment
Photodynamic Therapy
Macrene Alexiades-Armenakas
C h a p t e r
17
p a r t 2
Key Points
n Photodynamic therapy (PDT) has evolved from
the combination of systemic photosensitizers and
broadband light sources to topical photosensitizers
and pulsed light sources with minimal side effects.
n The protocol of topical PDT has dramatically
improved with the advent of short incubation times
and a variety of light sources.
n Numerous research studies have demonstrated the
safety and efficacy of topical aminolevulinic acid
(ALA) in conjunction with blue and red light, pulsed
dye (yellow) and red lasers, and intense pulsed
light sources for the treatment of actinic keratosis
(AK), actinic cheilitis, photodamage, and acne, and
for photorejuvenation.
n Recently, methyl aminolevulinate (MAL) has been
introduced as a second topical photosensitizer and
used in conjunction with red light for the treatment
of AK and basal cell carcinoma (BCC).
of actinic keratoses (AK), actinic cheilitis (AC), ­photodamage,
acne, or other skin disorders and for photorejuvenation. PDT
with MAL and red light has been developed for AK and
­potentially for BCC treatment.
History
The combination of a photosensitizer and light, termed photo­
chemotherapy, originated in ancient Egypt, India, and Greece for
the treatment of vitiligo and psoriasis with the application of
plant-extracted psoralens followed by exposure to sunlight.1–4
Modern PDT originated in 1900 from the work of a Ger­
man medical student, Raab, who discovered that combining
acridine orange and light in vitro killed Paramecium caudatum.5
Raab’s professor, Von Tappeiner, subsequently reported this
phenomenon to be oxygen-dependent and applied it as treat­
ment for skin neoplasia.6,7 Von Tappeiner coined the term
photodynamic action to describe this oxygen-dependent photo­
sensitive reaction.8
Various photosensitizers and light sources have been used
in PDT. Initially, systemic photosensitizers, such as hemato­
porphyrin,9 were combined with broadband red and blue
light sources to treat cutaneous neoplasia.10,11 The treatment
was strictly experimental for many years and caused marked
side effects, such as prolonged photosensitivity. In 1995, the
US Food and Drug Administration (FDA) approved porphy­
rin sodium systemic PDT for the treatment of esophageal car­
cinoma. Another major advance came with the introduction
of topical 5-ALA in the 1980s; it eliminated the problem of
generalized cutaneous photosensitivity.12,13 Topical ALA was
combined with red and blue light, the latter of which achieved
FDA clearance for treating actinic keratoses (AK) in 1997. In
the 1990s, red and, less often, blue light lasers were combined
with topical ALA to treat cutaneous neoplasms and inflam­
matory disorders such as acne. Despite these advances, ALA
PDT was still associated with significant side effects, such as
discomfort, crusting, blistering, erythema, dyspigmentation,
and localized phototoxic reactions.14 The introduction of
newer laser and light sources, including the long-pulse pulsed

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Cosmetic surgery procedures and techniques
dye laser (LP PDL) and intense pulsed light (IPL), combined
with ALA PDT resulted in enhanced efficacy and rapid treat­
ment and recovery, while diminishing unwanted side effects.15
Long-pulsed PDL PDT has been demonstrated to be safe
and effective in the treatment of AK, AC, photodamage, and
acne, with minimal discomfort, rapid treatment and recovery,
and excellent post-treatment cosmesis.6 ALA combined with
IPL has been demonstrated to improve the cosmetic outcome
from photorejuvenation.16,17
Science
The PDT reaction is mainly determined by the absorption
spectrum of the photosensitizer, and the wavelength and
penetration depth of the light. The porphyrins, the foremost
class of PDT photosensitizers, absorb light maximally in the
360–400 nm Soret band, with additional smaller peaks, the
Q bands, between 500 nm and 635 nm.18,19 5-ALA, which
is not photosensitizing, is converted into the photosensitizer
protoporphyrin IX (PPIX), which has a large blue peak at
417 nm and a small red peak at 650 nm in its absorption
curve.20 The penetration depth of light increases in direct
proportion to wavelength across the visible spectrum: for la­
sers, 50% penetration is 80 μm for 355 nm and increases to
1200 μm for 694 nm.21 Noncoherent light sources, while ex­
pected to achieve less optical penetration due to scatter, have
been reported to achieve up to 5 mm for 630 nm and 1–2 cm
for 700–800 nm.22–24 Taking these two factors into considera­
tion, most PDT research had employed wavelengths in the
blue range, which is optimally absorbed by porphyrins, and
the red range, which is less well absorbed, but penetrates more
deeply.19 More recently, wavelengths in the Q bands region,
such as PDL and IPL, have been employed in an effort to
diminish side effects, offering the advantages of greater pen­
etration than blue wavelengths, with adequate activation of
photosensitizer.
The classic ‘PDT reaction’ involved erythema and ­crusting,
and as discovered by Von Tappeiner (1903), is an oxygen-
dependent process.6,25 PDT is mediated by oxygen-dependent
photochemical reactions, during which photosensitizers are
excited from the ground state to a higher-energy singlet state,
and finally a reactive triplet state.4 From the triplet state, the
photosensitizer then reacts with oxygen to form reactive spe­
cies, such as singlet oxygen (the type II reaction) or directly
with a cellular target to form free radicals or radical ions (type
I reaction). Once singlet oxygen or free radicals have been
generated, their principle targets appear to be the cellular
and mitochondrial membranes, and endoplasmic reticulum,
leading to cell death. The mechanism of cell death in this
specific PDT reaction appears to be by apoptosis; it has been
demonstrated in cell culture experiments of carcinoma cell
lines following PDT with ALA and other photosensitizers.4
Ischemic necrosis from vascular compromise and local tissue
hypoxia has been implicated as a main culprit in the degree of
PDT reaction.4 The selectivity of the treatment may therefore
­depend upon the localization of photosensitizer in target cells,
and the degree of ischemia generated.
Strategies that diminish PDT side effects by allowing adequ­
ate tissue oxygenation may include lower irradiances, thereby
decreasing the rate of oxygen consumption, or dividing light
exposure into a series of shorter exposures in order to allow
for tissue reoxygenation. The latter is the strategy employed
by lasers, though LP PDL appears to efficiently clear target
with less inflammation and is devoid of necrosis as com­
pared to red lasers. A potential explanation for the ­efficient
clearance of precancerous cells without the degree of tissue
damage observed with other light sources may be that LP
PDL triggers apoptosis and the 10 ms light pulses delivered
at 1 Hz allow for adequate reoxygenation between pulses
such that ischemic necrosis is averted. Further investigation
is warranted to test this hypothesis. In sum, long-pulsed PDL
PDT may achieve target cell clearance through apoptosis
while minimizing side effects by averting the inflammatory
response and tissue ischemia, a plausible theory deserving of
further research.
Clinical studies
Systemic photosensitizers
and broad-spectrum light sources
Initially employed in PDT were predominantly broad-
spectrum light sources in combination with systemic photo­
sensitizers. In 1942, hematoporphyrin was used with a quartz
lamp to treat animal and human tumours.10 In the 1960s,
­hematoporphyrin derivative (HPD) was developed in com­
bination with a 600–660 nm xenon arc lamp.27,28 In the 1970s,
HPD was used with xenon arc lamps or slide projectors to treat
cutaneous malignancies in animal and human ­ studies.29,30
Through the 1990s, HPD was combined with slide projec­
tors emitting 400–650 nm using red filters, and halogen lamps
emitting 600–800 nm.30–34 Similar noncoherent light sources
were also combined with hematoporphyrin’s purified analog,
porphyrin sodium, to treat cutaneous malignancies.
Topical photosensitizers and broad-spectrum
light sources
In 1990, Kennedy and colleagues successfully treated AK
using topical ALA and a tungsten slide projector with a red
600 nm cut-off filter.13 Since then, topical ALA has become the
predominant photosensitizer-precursor employed for cutane­
ous conditions. Initially, noncoherent light sources in the red
range were employed, including tungsten light sources with red
filters,13,35,36 xenon arc lamps (600–720 nm),37 or halogen
lamps (570–690 nm).38 In the late 1990s, blue rather than red
light became the favored light source for the treatment of AK
due to the superficial localization of these precancerous lesions.
Topical ALA and blue light achieved FDA approval for the
treatment of AK in 1997.39 In the phase III study, which was

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Photodynamic therapy  •  Chapter 17
randomized, placebo-controlled, and ­ investigator-blinded,
89% of patients achieved greater than 75% clearing of AK at
12-week follow-up following one to two treatments with ALA
and blue light.40 ALA with blue light has since been shown
to be effective at short 1 hour incubation in treating diffuse
photodamage and AK.41,42 ALA and blue light treatment has
been reported for the treatment of acne, with lesional clear­
ance rates of 32% following one treatment. However, a phase
II FDA trial suggested efficacy only in severe cases.43
The methylated form of ALA, topical methyl aminole­
vulinic acid (MAL), has been combined with exposure to red
light for the treatment of skin neoplasia, recently achieving
FDA approval for AK with red light. AK clearance rates fol­
lowing MAL and red light were 93% for thin AK versus 70%
for thicker AK in one study44 and 89% for all AK in another
study.45 In a phase III randomized, cryotherapy-controlled
Australian trial, clearance rates were 91% for the MAL PDT
group, versus 68% for the cryotherapy group, versus 30%
for placebo PDT controls.46 In the European phase III cryo­
therapy-controlled trial, MAL PDT resulted in 69% complete
response versus 75% for cryotherapy.47
Although MAL with red light is not FDA-approved for the
treatment of nodular BCC, many studies have been conducted
for this application in the European Union, where it is ap­
proved. A retrospective study of superficial and nodular BCC
treated with MAL and red light demonstrated 89% complete
response following two treatments at 35-month follow-up.48
In a prospective, multicenter, randomized trial, nodular BCCs
treated with MAL and noncoherent red light resulted in 91%
complete response and 96% tumor-free rates at 12-month
­follow-up.49 A study of large or central-facial BCCs treated
with MAL and red light demonstrated complete response
rates of 78% at 24-month follow-up.50
Red and blue lasers with topical
and systemic photosensitizers
Lasers, predominantly in the red range and to a lesser extent
blue range, were introduced to PDT in the 1990s to treat in­
ternal and cutaneous conditions. Lasers provided the ability
to be coupled to fiberoptics for access to internal tumors, to
select a specific wavelength and maximize penetration depth,
and to achieve higher irradiances thereby decreasing exposure
times.51 Initially, systemic photosensitizers, such as HPD and
porphyrin sodium, were combined with red wavelengths, such
as the tunable dye (630 nm) or gold vapor (628 nm) lasers, and
blue-green wavelengths from the argon (488 nm and 514 nm)
lasers.52 Most recently, systemic verteporphyrin and red diode
laser (688 nm) were used to treat squamous cell carcinoma
(SCC) and BCC with histopathological tumor clearance rates
of up to 95%.53 Thus, red and blue lasers combined with syste­
mic porphyrin photosensitizers have been used to treat internal
and cutaneous malignancies.
When topical ALA was introduced, it was combined with
lasers to treat cutaneous neoplasms. These lasers were pre­
dominantly of red wavelengths, such as the copper vapor-dye
(630 nm), the neodymium:yttrium-aluminum-garnet (Nd:
YAG) (630 nm), and the argon ion-dye (630 nm) lasers.54–59
The clearance rates depended upon the type of neoplasm.
Complete clearance of AKs ranged in several studies from
80% to 100% (averaging 92%) with a 3–12-month follow-
up.60 For BCC, complete clearance was reported in a mean
of 53% of nodular and 87% of superficial BCCs with 3–36-
month ­follow-up depending upon the study.60 For SCC, these
clearance rates were 25% for nodular and 81% for superficial
SCC with 3–35-month follow-up depending upon the study.60
Rec­ently, ALA PDT was studied using an argon pumped-dye
(633 nm) laser as compared to a filtered tungsten-halogen
(590–700 nm) lamp for treatment of the basal cell nevus syn­
drome.61 Median response rates of 82–90% were achieved for
the laser as compared to 50–75% for the lamp following each
treatment.61
Topical ALA has also been combined with use of red light
lasers and light to treat acne, however, with the disadvantage
of significant side effects. Topical ALA and broadband red
light research demonstrated that ALA-induced PPIX fluores­
cence was greater in acne lesions than in surrounding normal
skin and that sebaceous gland size was diminished following
PDT.62 When red broadband light (550–700 nm) was used in
conjunction with ALA incubated for 3 hours under occlusion,
significant side effects such as blistering, erythema, edema, and
dyspigmentation were observed.62 Similar side effects were
­reported in another study utilizing topical ALA incubated for
3 hours and irradiation with a red diode laser at 635 nm for
the treatment of back acne.63 Another study comparing blue
(415 nm) to red (660 nm) light demonstrated a mean improve­
ment in acne counts of approximately 50% at 1 month after
daily treatments with red and blue light combined, as opposed
to 30% with blue light alone.64 Longer red wavelengths yielded
higher efficacy rates, presumably due to the shallower pen­
etration depth of blue wavelengths. Similarly, improvement in
acne was reported among patients treated with topical ALA
in conjunction with a 635 nm laser65,66 and a polychromatic
(600–700 nm) light;66 however, use of both light sources was
accompanied by significant side effects of crusting and hyper­
pigmentation.
Long-pulsed pulsed dye laser with topical
aminolevulinic acid
The disadvantage of the red and blue light and laser sources
had been the association with significant side effects, thereby
prompting the search for alternative light sources. Along the
absorption spectrum of PPIX among the Q bands, there is a
peak at 575 nm.20 The initial combination of topical ALA and
the 585 nm PDL for the treatment of AK resulted in good ef­
ficacy but cosmetically unacceptable purpura and significant
side effects such as crusting.26 More recently, the combination
of topical ALA and the 595 nm LP PDL operated at long
pulse durations eliminated these side effects while maintain­
ing efficacy of AK clearance.15

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Cosmetic surgery procedures and techniques
Actinic keratoses
In the first study of long-pulsed PDL PDT of 41 patients with
AK, ALA was applied for 3 hours versus 14–18 hours of in­
cubation followed by LP PDL irradiation.15 The patient mean
percentage head AK lesions cleared was approximately 90%
at 8-month follow-up, which was comparable to other treat­
ment modalities such as topical fluorouracil or PDT with blue
light.15 In addition to high efficacy rates, LP PDL-mediated
PDT achieved rapid treatment times of less than 5 minutes for
full head; minimal discomfort; and minimal post-­treatment
erythema, which resolved within 5 days. There was no inci­
dence of blistering, crusting, or dyspigmentation. This was the
first clinical study to demonstrate that short incubation (3 h)
ALA was as effective as long (14–18 h).15 These findings have
since been reproduced with short-incubation ALA and blue
light.41 An example of a patient with numerous AK prior to,
immediately following, and 2 weeks after one treatment with
long-pulsed PDL PDT is shown in Figure 17-1.
Photodamage
An evident extension of this application for AK is the use of
long-pulsed PDL PDT for the closely related condition of pho­
todamage or actinic damage. While improvement in texture
and erythema were expected from AK clearance, improve­
ments in fine rhytides and lentigines were also observed. Pho­
tographic examples of a patient with extensive photodamage
prior to, immediately following LP PDL-mediated PDT and
after 2 weeks are shown in Figure 17-1. Treatment of photo­
aging with long-pulsed PDL PDT has been reported.67 Fur­
ther research in this area of PDT has mainly employed the
IPL in conjunction with topical ALA PDT, given the well-
documented efficacy of IPL alone for this application. The
addition of ALA has been used to accelerate photorejuvena­
tion and decrease treatment numbers.16,17
Actinic cheilitis
Aminolevulinic acid (ALA) PDT activated by LP PDL (595 nm)
was subsequently found to be safe and effective with mini­
mal side effects for related precancerous condition AC for
which alternative treatment options have been of limited
­efficacy.68 In a study of 21 patients with refractory AC, 20%
topical ALA was applied for a short 2-hour incubation fol­
lowed by two passes of LP PDL (595 nm) at 7–7.5 J/cm2 flu­
ence, 10 ms pulse duration, 10 mm spot size, and dynamic
cooling spray of 30 ms with 30 ms delay.68 Complete clear­
ance was achieved in 13/19 (68%) of patients following a
mean of 1.8 treatments: 7/13 (37%) cleared after one, 2/13
(11%) after two, and 1/13 (21%) after three treatments with
a mean ­ follow-up of 4.1 (range 1–12) months. Side effects
were minimal with none-to-mild pain, slight-to-moderate
erythema lasting less than 3 days, and no crusting, purpura,
or scarring.68 A patient with AC prior to and 2 years follow­
ing a single treatment with long-pulsed PDL PDT is shown in
Figure 17-2.
Acne
The rationale for PDT to treat acne was initially based upon
the fact that porphyrins are produced in small quantities by
Propionibacterium acnes.69 In obstructed follicles, the anaero­
bic bacterium proliferates and incites inflammation. When
exposed to light, a PDT reaction occurs in the acne lesions
causing singlet oxygen production and bacterial destruction.70
Blue light without ALA has been of modest or yet questioned
efficacy in the treatment of acne, presumably due to its poor
depth of skin penetration.64 In contrast, red light, while less
effective at porphyrin photoactivation, penetrates deeper and
when combined with blue light increases effectiveness.64
In addition, exogenous ALA concentrates in sebaceous
units; therefore, topical ALA increases efficacy of PDT for
acne. When ALA was injected intraperitoneally into mice,
PPIX accumulated in the sebaceous glands of normal skin
and light of the appropriate wavelength destroyed sebaceous
glands.71 Topical application of ALA induced selective PPIX
fluorescence in acne lesions with minimal background in sur­
rounding normal skin.62,63 PDT with red light was shown to
shrink sebaceous glands but with significant side effects.62
Since LP PDL with ALA PDT was effective in reducing
sebaceous hyperplasia,72,73 it was evaluated for the ­treatment
A
B
Fig. 17-1  (A) Immediately before AK and (B) 2 weeks after one treatment with long-pulsed PDL PDT for AK.

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Photodynamic therapy  •  Chapter 17
of acne. In an initial pilot study, a 50–60% reduction in mean
acne counts was observed after one treatment with minimal
erythema lasting approximately 2 days.72 Recently, a con­
trolled pilot study assessing LP PDL-mediated ALA PDT
­combined with topical therapy for the treatment of acne was
completed using ALA for 45 minutes followed by LP PDL.74
The patient mean percentage clearance rates per treatment
were: 77% for long-pulsed PDL PDT, 32% for LP PDL
alone, and 20% for conventional therapy, which included
oral antibiotics and oral contraceptives, while all patients
were maintained on topical therapy.74 The blue light arm of
the study was curtailed due to recrudescence in the blue light
group. Following long-pulsed PDL PDT, minimal erythema
was ­observed lasting 1–2 days with no incidence of crusting,
purpura, scarring, or dyspigmentation. Figure 17-3 shows
an ­example of a patient with acne vulgaris prior to and fol­
lowing a single treatment with long-pulsed PDL PDT. Thus,
­adequate efficacy with minimal side effects were achieved with
LP PDL in combination with ALA PDT and topical therapy;
however, a randomized, double-blind, vehicle-controlled trial
of monotherapy is pending.
The mechanism of acne clearance may involve blood ves­
sel targeting as well as photothermal effects on sebaceous fol­
licles and weak but adequate photoactivation of endogenous
porphyrins produced by P. acnes in the sebaceous follicle. Sup­
portive evidence that PDT targets the sebaceous gland is well
demonstrated by decreased sebaceous gland size and vacuoli­
zation of sebocytes following PDT.62 Thus, the mechanism
of PDT in treatment of acne likely involves direct thermal
or photodynamic injury to the sebaceous glands, destruction
of P. acnes, or a facilitation of keratinocyte turnover in the in­
fundibulum.62 The number of treatments needed to achieve
acne clearance may be due to hormonal factors and the size
and activity of the sebaceous glands at baseline, such that
multiple sessions are required in order to achieve adequate
destruction of sebaceous gland function.
Intense pulsed light and topical
aminolevulinic acid
More recently, IPL has been employed, which is absorbed by
PPIX at multiple peaks across its Q band region from 500 nm
to 1200 nm, also with minimal side effects. The use of IPL
A
B
Fig. 17-2  (A) Prior to AC and (B) 2 years after a single treatment with long-pulsed PDL PDT for AC.
A
B
Fig. 17-3  Acne prior to (A) and following (B) a single treatment with long-pulsed PDL PDT.

254
Chapter 17
Cosmetic surgery procedures and techniques
for PDT is appealing since it spans wavelengths from the blue
to the infrared range, thereby exciting PPIX along many of
its successive peaks in absorption. In addition, it is a device
which has many uses from rejuvenation to hair removal and
is therefore popular among dermatologists and physicians in
other fields. The combination of ALA has expanded its ap­
plications to include AK and photodamage, and most recently
acne. The advantages of this light source therefore include its
versatility; however, the disadvantage is also its variability in
level or response and side effects as discussed below.
Actinic keratosis and photodamage
In the last few years, IPL-mediated ALA PDT has been stud­
ied for the treatment of AK and photodamage and has yielded
variable results. The term photodynamic photorejuvenation
has been applied to the use of IPL in the treatment of AK
and photodamage.16 In one study of 17 patients treated with
two ALA IPL treatments for AK, a clearance rate of 87%
was achieved to 3-month follow-up; however, crusting was ob­
served which took 1 week to resolve.16 A retrospective study
reported 68% clearance of AK following one treatment and a
50% improvement in telangiectasia and texture.75 The com­
bination of topical 5-fluorouracil for 1 week followed by topi­
cal ALA for a 45-minute incubation and IPL (560–1200 nm)
demonstrated up to 90% clearance of AK at 1-year follow-
up.76 Erythema persisted for 7–10 days.76 Another study of
individual AKs demonstrated only 50% clinical clearance
and 42% histological clearance after a single ALA IPL treat­
ment.77 Thus, the efficacy rates and side effects reported for
AK clearance with IPL PDT have been variable, likely due
to the inconsistency of the incubation times and the different
IPL devices utilized among the studies.
Photorejuvenation
Among all the light sources, IPL combined with ALA PDT has
been the most extensively studied for use in photorejuvenation;
this largely stemming from the fact that IPL has independently
been shown to rejuvenate skin while spanning wavelengths that
activate PPIX. A split-face design clinical study ­comparing ALA
IPL to IPL alone demonstrated greater improvement on the
ALA side following two-monthly treatments.78 Another IPL fol­
lowing a 1–2-hour incubation of topical ALA resulted in crust­
ing when fluences above a certain threshold were delivered.79
A recent randomized, blinded, split-face design study evalua­ted
the addition of ALA to IPL treatment for skin rejuvenation.
The ALA resulted in a marked improvement in the efficacy
of IPL in treating fine rhytides, dyspigmentation, and eryth­
ema. A randomized, split-face design study comparing ALA
and IPL to IPL alone demonstrated marked improvement in
efficacy on the ALA side in decreasing erythema, dyspigmen­
tation, and fine rhytides.17 ALA IPL appears to be relatively
less predictable both in clinical response and side effect profile,
likely due to the variability of different IPL devices in wave­
length irradiances. Overall, the response and accompanying
side effects from IPL PDT may range from none to marked.
Acne
The use of PDT to treat moderate to severe acne has also
recently been investigated with IPL.80,81 One study reported
the use of IPL following 1-hour incubation ALA in which 12
of 15 patients responded.80 Reductions in lesion counts were
50.1%, 68.5%, and 71.8% at the end of the 4-week period
of once-weekly treatments, 4 weeks after the final treatment,
and 12 weeks after the final treatment, respectively.76 Treat­
ments were administered weekly, were well tolerated, and no
treated lesion returned during the follow-up period.80 In an
18-patient study, ALA PDT with activation by blue light or
electro-optical synergy (ELOS), a combination of optical and
radiofrequency energy, was studied.81 ALA incubation time
was limited to 15–30 minutes. Patients received two to four
ALA PDT treatments during a 4–8-week period or, over a
4-week period, ALA PDT at weeks 2 and 4 and salicylic acid
peel at weeks 1 and 3. Acne improved in 12 patients; in 11
of these patients improvement was 50% and in 5 patients
­improvement exceeded 75%.81
Discussion
Since the beginning of the twentieth century, photodynamic
therapy has evolved from a systemic treatment with multiple
side effects to its adaptation for cutaneous use as a topical
treatment with minimal side effects for a variety of skin condi­
tions. Initially, the use of systemic photosensitizers and broad-
spectrum incoherent light sources to treat malignancies was
associated with prolonged photosensitivity and side effects.
The field evolved with the introduction of topical ALA and
the advent of lasers. Red- and blue-spectrum lasers and light
sources, while effective in treating skin neoplasia and other
disorders, were complicated by unwanted side effects, such as
pain, blistering, crusting, and dyspigmentation. The develop­
ment of short incubation ALA and of newer light sources for
use with ALA PDT, such as long-pulsed PDL and IPL for the
treatment of photodamage, actinic keratoses, and acne has
dramatically minimized any side effects while maintaining ef­
ficacy. Newer topical photosensitizers, such as MAL and oth­
ers in development, will also continue to advance and refine
the field.
Procedures and Techniques
Preoperative clinical
considerations
Actinic keratosis and photodamage
Patients with type I skin and excessive actinic damage, regard­
less of treatment option chosen, be it PDT or topical thera­
pies, are at higher risk of developing significant erythema.
Therefore, these patients should be educated preoperatively

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Photodynamic therapy  •  Chapter 17
as to strict light avoidance for 2 postoperative days following
PDT regardless of protocol. Their treatment is best sched­
uled during a time where their social schedule is clear for 2–3
postoperative days, optimally avoiding the summer months. A
4-inch broad-brimmed hat made of light impervious material
should be obtained by the patient ahead of time and bought
in on the day of treatment. An instruction sheet containing
pre- and post-treatment instructions should be given to the
patient on the day of consultation, ahead of the scheduled
treatment date. Typically, patients are not premedicated with
antiviral or antibacterial antibiotics, except in the case of a
history of herpes simplex or staphylococcal infections in the
setting of AC (see below). Examples of the instruction sheet
and a consent form based on those used in the author’s prac­
tice is shown in Appendices A and B.
Actinic cheilitis
The most important preoperative considerations in PDT for
AC include history of herpes labialis, staphylococcal infec­
tions of the face, or immunosuppression and evidence or
erosive or ulcerative AC. Patients with a history of herpes
labialis or herpes simplex viral infections of the facial skin
should be premedicated with famciclovir 250 mg p.o. b.i.d.
starting the day prior to the procedure for a 5-day course.68
Those with a history of staphylococcal infections of the facial
skin should be premedicated with dicloxacillin 250–500 mg
p.o. q.i.d. starting 1 day prior to the procedure for a 5-day
course. Patients taking immunosuppressive medications, such
as prednisone, or who are immunosuppressed, should also
be premedicated with dicloxacillin or an appropriate anti­
biotic, as these patients are at increased risk of developing
postoperative impetigo.68 Finally, patients with erosive AC are
also premedicated with dicloxacillin, as they fall into this risk
category.68
Patients with AC do not experience the degree of erythema
that AK patients do. However, bright light avoidance for 2
postoperative days is still recommended. In addition, these
­patients are instructed to wear a broad-brimmed hat the first
2–3 days following treatment.
Acne
The various treatment options for acne patients should be
reviewed in detail. Once it has been established that the pa­
tient is resistant to conventional therapy, including topical
medications, oral antibiotics, oral contraceptives or isotretin­
oin, PDT is an alternative option. Oral isotretinoin and la­
ser treatments that are FDA-approved, such as Clearlight
or Smoothbeam, should also be discussed beforehand. This
is an off-label use of PDT, and it is the author’s opinion
that the patient should be informed of this fact during the
consultation.
Patient selection is important since complete clearance
­requires high patient compliance. Complete clearance may
require as many as six treatments spaced at monthly inter­
vals and early dropout may not yield favorable results.70
­Patient ­selection is important, as in the author’s experience,
the ­ teenaged male and athletically active populations tend
to be less ­ willing to undergo regular monthly treatments
which restrict sun exposure for 2 postoperative days. Patients
are ­ instructed beforehand that they should wear a broad-
brimmed hat for the 2 postoperative days. Patients who have
severe cystic acne who have failed isotretinoin should also be
informed that an initial worsening of their acne may occur
during the first postoperative week followed by improvement.
Overall, the degree of erythema is typically mild and does not
inhibit most social activities.
The timing of treatments is of significant importance. Dur­
ing the course of investigation, it was observed that patients
who delayed beyond 5 weeks for re-treatment experienced
gradual worsening.74 Thus, the treatment protocol of treat­
ment intervals of 3–5 weeks is best adhered to if complete
clearance is to be achieved.
Photorejuvenation
During the consultation, patients should be advised that the
addition of ALA to photorejuvenation protocols typically
res­ults in mild erythema for 2–3 postoperative days. Typi­
cally, premedication for herpes simplex or staphylococcal
infections is not recommended for this nonablative technol­
ogy. During initial consultation, it is important to instruct
the patient that for the first ALA IPL treatment, the degree
of erythema or PDT response varies considerably. One may
anticipate as little as no reaction to a significant degree of
erythema and desquamation. This variation is likely depend­
ent upon the IPL device output and degree of photodam­
age. First-time patients need to be prepared for the rare case
where significant erythema may occur. Patients should also
be advised that while ALA augments the degree of improve­
ment from photorejuvenation, multiple treatments are still
required.17
Procedural techniques
The general protocol regardless of photosensitizer or light
source involves the application of a photosensitizer precur­
sor for a defined incubation time, followed by irradiation with
the light source at the appropriate settings. The two FDA-ap­
proved topical photosensitizers discussed herein include ALA
and MAL. The light sources include the FDA-approved blue
light (Blu-U) for use with ALA and red light for use with MAL,
as well as the most common currently used alternative light
sources, including LP PDL and IPL.
Aminolevulinic acid and blue light
Actinic keratosis and photodamage
Aminolevulinic acid application.  According to the label
and per the package insert, 5-ALA topical 20% solution (Lev­
ulan, DUSA pharmaceuticals) had initially been applied in