Nonablative and Ablative Skin Rejuvenation
Julie Woodward, MD
DISEASE DESCRIPTION
The aging face involves loss of collagen, elastin, and subcutaneous fat. Reactive oxygen species and free radicals from sunlight, pollution, and other stressors cause skin cells to enter apoptosis and be destroyed. With these stressors, the immune system of the skin is compromised, and its wound healing capabilities are weakened. The dermal-epidermal junction loses its integrity and the skin barrier function is less protective because metalloproteinases degrade collagen, fibroblasts are lost, and the vascular support network is decreased. Abnormal amorphous elastic material is deposited in the skin as a result of dermal elastosis. Clinically, this results in rhytides (wrinkles), dryness, atrophy, roughness, sagging, and irregular pigmentation, which are all indications for treatment.
MANAGEMENT OPTIONS
Lasers (both ablative and nonablative) and energy-based devices (including radiofrequency, intense pulsed light (IPL) or broadband light, and microfocused ultrasound) have the ability to minimize dyschromias and create collagen contraction and collagen neogenesis. The common pathway of these modalities is the creation of heat.
The following are general categories of devices used for skin rejuvenation. The physician must decide what type of device would fit into their practice, the requirements of local regulations, and who within the practice will perform the procedure. Because the field is so broad, attending multiple courses to learn more about a variety of devices in depth is recommended.
Ablative lasers
Carbon dioxide (traditional or fractional, 10,600 nm)
Erbium Er:Yag (traditional or fractional, 2940 nm)
Water is the chromophore for these lasers.
Epidermal layer of skin is vaporized.
Useful for treating
Rhytides
Skin atrophy, roughness, and sagging
Downtime is usually 7 to 10 days, which makes these lasers a good complement to concurrent blepharoplasty. Greater downtime results in more dramatic results.
Nonablative lasers
Wide variety of nonablative laser wavelengths
Nd:YAG (1319 nm, 1320 nm, 1410 nm-1440 nm)
Erbium glass (1450 nm, 1540 nm, 1550 nm, 1565 nm, 1927 nm)
Thermal damage occurs in the dermis, where the controlled injury generally produces a milder effect with a shorter downtime.
Useful for treating fine facial rhytides and acne.
Vascular lasers
532 nm potassium titanyl phosphate (KTP)
585-595 nm pulsed dye
755 nm long-pulsed alexandrite
800 nm diode
1064 nm long-pulsed Nd:Yag.
Hemoglobin is the chromophore.
IPL or broadband light
Utilizes a bright white flash lamp that is delivered along a fiberoptic arm with a filter at the working end to ensure only certain wavelengths are emitted to the skin.
This is best to treat pigmentary irregularities and vascular lesions and erythema, rather than rhytides.
Treatment to the cheeks for rosacea can also be performed, as well as adjunct treatment for dry eye.
Radiofrequency
Can be delivered unipolar or bipolar, either transdermally or via concurrent microneedling.
One advantage to this treatment is that it can be used on the neck, where lasers cannot effectively be used because of the risk of scarring.
Microfocused ultrasound
Involves converging rays of ultrasound beneath the skin to tighten the submuscular aponeurotic system (SMAS).
The treatment is approved by the U.S. Food and Drug Administration (FDA) to “lift” rather than resurface.
It can be used on the face and neck.
A complete discussion of the differences between the many available nonablative lasers and energy-based devices is beyond the scope of this chapter; the technique described here is the use of the ablative laser.
SURGICAL DESCRIPTION
Preoperative Considerations
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