Treatment Of Rhytides Research Articles

The history of botulinum toxin and its relationship to the skin

Botulinum toxin was first identified as the cause of muscle paralysis in cases of food poisoning in the 1800s. Further study of the toxin gained insight into its mechanism of action and potential for therapeutic use. “Oculinum,” now known as onabotulinumtoxinA (Botox), was approved for clinical use in 1989 for the treatment of strabismus, blepharospasm, and hemifacial spasm. The first published cosmetic use was in 1992 describing successful treatment of glabellar lines. OnabotulinumtoxinA became approved for treatment of rhytides in 2002, followed by abobotulinumtoxinA (Dysport), incobotulinumtoxinA (Xeomin), and prabotulinumtoxinA-xvfs (Jeuveau) in 2009, 2010, and 2019, respectively. Since the initial approval of onabotulinumtoxinA 20 years ago, neuromodulator injection has become the most popular nonsurgical aesthetic procedure in the world.

Botulinum Toxins in Medical and Cosmetic Dermatology

Background: Botulinum toxin (BoNT), a bacterially produced neurotoxin, is a mainstay in the dermatologic armamentarium. Although BoNT is commonly used to treated rhytides associated with ageing, it can be employed for a variety of other cosmetic purposes and medical disorders. Objective: In this review, the authors aim to describe the multitude of uses for BoNT in the dermatologic field. Materials and Methods: This manuscript was designed as a retrospective review of the on- and off-label applications of BoNT in dermatology.Results: In addition to treatment of rhytides, BoNT has been shown to decrease rosacea, menopause-associated flushing, and facial sebum production, while improving patient confidence in their appearance. Furthermore, BoNT has been successfully used to treat primary hyperhidrosis, hair loss, aberrant scarring, Raynaud’s phenomenon-associated vasospasm, as well as a variety of skin diseases. Side effects of BoNT include pain or discomfort associated with injections during treatment, bruising, asymmetry, and swelling. Patients are generally satisfied with clinical results after BoNT treatment. Conclusion: Dermatologists should be aware of all on- and off-label applications of BoNT to provide patients with timely and appropriate medical care. Further research must be completed to fully characterise the safety and use of BoNT for off-label purposes.

Millennials Are Interested in Botulinum Toxin Injections for Prevention of Facial Rhytids

Background: Botulinum toxin has been utilized for the treatment of facial rhytids since 2002. Since development, the indications for botulinum toxin have expanded greatly. Typically utilized in older generations for the treatment of rhytids, younger generations may be pursuing botulinum toxin injections for prevention rather than solely treatment of rhytids at a younger age. Methods: A 26-question survey was designed on Qualtrics and distributed to people through Amazon Mechanical Turk (MTurk) system. The Data was extracted from the Qualtrics website and processed with Microsoft Excel. Results: Out of 516 completed surveys, 92% of respondents were familiar with botulinum toxin injections with 21% having received botulinum toxin injections and 18% have received injections for cosmetic indications. Of those who have received botulinum toxin injections, 45% utilized injections for the treatment of wrinkles, 37% for the prevention of wrinkles, and 18% for the management of a non-cosmetic indication. When all respondents were asked the purpose of botulinum toxin injections, 11% thought they were for the prevention of wrinkles, 25% believed they were for the treatment of wrinkles, while 63% believe they are for both the prevention and treatment of wrinkles. Conclusions: Younger patients are pursuing botulinum toxin injections at an earlier initial age than their older counterparts. Significantly more people believe that these injections are intended for the prevention and treatment of facial rhytids rather than treatment alone. Plastic surgeons must be aware of the shifting landscape in order to adequately access this increasing patient population.

A Study to Examine the Effect of Needle Gauge on Pain Perception in Patients Receiving Treatment With Botulinum Toxin in 2 Different Anatomical Areas

Botulinum toxin injection for treatment of rhytids is the commonest cosmetic intervention undertaken worldwide. It requires re-treatment at 3-month intervals for the effect to remain. Consequently, patient comfort is paramount in order for the procedure to remain acceptable. Intuitively, patients expect that smaller needles will be less painful, and this study examines the pain caused by needles of 2 gauges (31 and 32) when administering botulinum toxin in 2 anatomical areas. Patients were randomized into having the left or right side of their face treated with either a 31- or 32-gauge needle during botulinum toxin administration. Participants were asked to determine whether the left- or right-side treatment was most painful. The study was repeated in the glabellar and paraorbital regions. A total of 103 participants entered the study; 98 had the glabellar region treated and 76 the crow’s feet, and 72 patients had both regions treated. For the glabellar region, the smaller 32-gauge needle was significantly more painful than the larger 31-gauge needle ( P < .01). There was no difference in patient’s pain perception between gauges of needle when treating the crow’s feet area ( P = .9). The 31-gauge needles produce significantly less pain than smaller 32-gauge needles when treating the glabellar region with botulinum toxin, but not in the periorbital region. We propose that this is due to differences in fascial adherence between the 2 areas. Consequently, we would recommend administering botulinum toxin with a 31-gauge needle in all areas.

Efficacy of Laser Resurfacing and Facial Plastic Surgery Using Age, Glogau, and Fitzpatrick Rating.

Background:To assess clinical outcomes based on established rating scales in patients who underwent treatment for rhytids using laser resurfacing with and without facial plastic surgery.Methods:Retrospective case review of 48 patients treated by the senior author (J.E.B) between 2009 and 2016. Three reviewers assigned ratings to a total of 48 patients using estimated age and Fitzpatrick, Modified Fitzpatrick, and Glogau scales. Reviewers were blinded to patient demographics and before and after photographs. Patients elected to receive laser-only treatment or combination laser plus facial plastic surgery. Participants included forty-eight patients were selected on the basis that they had either laser treatment alone or laser plus facial plastic surgery and pre- and postoperative photographs.Results:Patients with higher Fitzpatrick scores had a greater reduction in Glogau score (ß = 1.66; SE = 0.59; P < 0.01). With respect to modified Fitzpatrick scores after surgery, patients with higher Glogau scores of 3 or 4 before surgery (P < 0.01) had higher scores after surgery ((ß = 0.07; SE = 0.02; P < 0.01). For estimated age, the average change was -1.7 years after laser resurfacing (P = 0.038; 95% CI, 2.96–3.06 years) and -2.07 years when combined with surgery (P = 0.01; 95% CI, 2.89–3.19 years).Conclusions:Patients with Fitzpatrick scores of 3, 4, 5, younger patients, and those with less rhytids before surgery tended to have lower Glogau scores after surgery. These findings provide insight on an approach to treating ethnic skin and aging face concerns.

Laser treatment of periocular skin conditions

Advances in laser technology in recent decades have increased the options for the treatment of dermatologic conditions of the eye and eyelid. Benign tumors can be laser-ablated with relative ease, and vascular and melanocytic lesions can be precisely targeted with modern lasers. In this contribution, we review treatment of periocular pigmented lesions, including melanocytic nevi and nevus of Ota; vascular lesions including telangiectasias, port wine stains, and infantile hemangiomas; hair removal; eyeliner tattoo removal; laser ablation of common benign periocular tumors, such as syringomas, xanthelasma, milia, and seborrheic keratoses; and laser resurfacing. The recent advent of fractionated laser technology has resulted in dramatically decreased healing times for periocular skin resurfacing and fewer adverse effects. Fractionated laser resurfacing has now nearly supplanted traditional full-field laser resurfacing, and safe treatment of rhytides on the thin skin of the eyelids is possible. Proper eye protection is, of course, essential when using lasers near the eye. Patient preparation, safety precautions, and risks—intraocular and extraocular—are discussed herein. As laser technology continues to advance, we are sure to see improvements in current treatments, as well as development of new applications of cutaneous lasers.

Novel use of polymethyl methacrylate (PMMA) microspheres in the treatment of infraorbital rhytids

To demonstrate safely with the use of polymethyl methacrylate (PMMA) microspheres in the infraorbital eyelid area using a deliberate conservative injection in the treatment of rhytids. A retrospective case series of 289 patients in an outpatient cosmetic dermatology clinic evaluated and treated by one senior provider (NM) of infraorbital rhytids with PMMA from December 2010 to March 2011. Statistical analysis was performed for race, skin type, history of hypertrophic scar, autoimmunity, history of "sensitive skin" and history of prior procedures such as prior facelift, rhinoplasty, and blepharoplasty. Two hundred ninety-one patients underwent at least 1-6 injections of PMMA microspheres into bilateral under eye area. Early complications were edema and ecchymosis. Late complications were identified in 4 of 289 patients who developed small granulomas. All patients who developed granulomas had had a previous lower blepharoplasty (P=0.00). A history of "sensitive skin" was approaching statistical significance (P=0.15). This study has shown that PMMA microsphere injection is a safe subdermal technique in the correction of infraorbital rhytids. Safety was demonstrated in 289 patients with only 4 minor complications of small lateral granuloma which all resolved within 4weeks after intralesion triamcinolone injection. However, this is an off-label use of a permanent filler not approved for use in the infraorbits and significant caution must be taken with full disclosure to the patient leading to informed consent. Caution in PMMA microsphere injection should be given in the patient with prior blepharoplasty. The advantage of PMMA microsphere is that the result seems to be predictable and natural.

Short flap rhytidectomy and fractional CO2 laser rejuvenation of the aging face

There is currently a high demand for a concurrent system of skin rejuvenation accompanying rhtidectomy. CO2 laser treatment prior to surgical ablative reduction has produced promising results, but the adjunct service of laser treatment at the time of surgery has never been reviewed. Determine the effects of concurrent treatment of rhytides and evidence of aging in the skin with surgical correction followed by fractional CO2 laser application. During study time from September 2008 to February 2009 treat patients who have underwent short flap rhytidectomy to the Lutronic eCO2™ fractional laser using the patented "Controlled Chaos Technology." Complications included 2.3% herpes simplex outbreak, 4% persistent erythema past 2 weeks, four cases of prolonged edema to 5 days, one case of impetigo, and no evidence of dyspigmentation. Patient satisfaction data demonstrated no refunds at 12 months. Combination fractional laser resurfacing with short flap, high-Superficial muscular aponeurotic system rhytidectomy is a safe procedure with excellent patient satisfaction and clinical outcomes.

Autologous Fat Transfer for Face Rejuvenation with Tumescent Technique Fat Harvesting and Saline Washing: A Report of 215 Cases

Various materials have been used for tissue augmentation and for the treatment of rhytids. Autologous fat transfer (AFT) is considered ideal regarding biocompatibility and patient concerns. This study was performed on a series of 215 female patients for face rejuvenation with tumescent technique fat harvesting and saline washing. The study was based on two AFT procedures for each patient. Second treatment was performed at least 1 month after the first operation. Their mean age was 55.5 ± 2.1 years. High-definition photographs in five standard views, front (n = 1), side (n = 2) and oblique of 3/4 (n = 2), were taken for the preoperative morphological study. Aesthetic outcomes were evaluated by the operating surgeon, the patient and an independent dermatologist. Outcomes were evaluated by comparing the preoperative photographs with those taken 1 month after the first procedure and at the end of the 1-year follow-up period. At 12 months all the patients except one noted an improvement. Of these 85.6% (184 patients) were satisfied with the treatment. The operating surgeon and the independent observer noted respectively a sufficient correction in 88.8 and 95.3%. AFT was considered painless by 94.9% and slightly painful by 5.1% of subjects. Fat tissue harvesting by tumescent anesthesia and purification with saline washing enable adipocyte viability to be preserved throughout the procedure and to perform the treatment under local anesthesia.

Office‐Based Facial Plastic Procedures for Otolaryngologists

Program Description: The modern otolaryngologist has had residency-based, and in many cases, advanced fellowship training in a wide spectrum of facial plastic and reconstructive procedures to correct congenital-, acquired-, and aging-related deformities. Due to advances in technologies, there has been an increase in the ability to offer patients a variety of effective and minimally invasive interventions in the office setting. Among these interventions, the use of injected botulinum toxin has become common in the treatment of rhytids, hyperfunctional lines, and facial dystonias. The treatment of skin and subcutaneous contour deformities is also a common challenge for which patients seek consultation. Although previously the materials used for correction were limited in number, there has now been an increasing number of widely used and newly introduced materials made available to the practitioner. The introduction of hyaluronic acid–based agents created a significant increase in acceptance and demand for filler substances by patients. More recently approved and soon to be approved fillers promise to increase the application. Laser and light technologies, including laser hair removal, offer intervention for an increasingly large number of clinical issues including the treatment of wrinkles, hyperpigmentation, cutaneous vascular lesions, rosacea, unwanted hair, and other aging-related skin conditions. Finally, although not representing new technology, but instead low-cost effective treatments, the practitioner will find the availability of skin care services, particularly the use of various chemical peeling agents, to be a useful adjunct in the office setting. The purpose of the miniseminar is to present an up-to-date review of safe, effective office-based procedures that the otolaryngologist may have available to patients in their office. The presentations will review the pertinent pharmacology, physics where applicable, and anatomy. Technique, preoperative and post procedure issues will be discussed. The clinical photo-rich presentations will demonstrate technique and patient selection. The prevention and management of complications will be reviewed. This miniseminar will update the attendees that have previous training in these procedures and serve as an introduction to those that are exploring these procedures. Educational Objectives: 1) Learn the indications and techniques for cosmetic botulinum toxin injections. 2) Learn the indications and techniques for facial filler injections. 3) Learn the indications and techniques for chemical peels, lasers, and light-based devices.

Prospective, uncontrolled examination of ablative fractional photothermolysis on Asian and Caucasian skin

Abstract Background and objectives Ablative fractional carbon dioxide (CO2) laser treatment has gained popularity for several clinical indications due to its superiority in the treatment of rhytides, scars and photodamaged skin. The concept of ablative fractional photothermolysis (AFP) enables the induction of dermal coagulative injury without confluent epidermal damage, reduces side effects and shortens downtime. To date, less is known about its safety and efficacy on Asian skin where dyspigmentation is suspected to be one of the most challenging adverse events. Materials and methods 78 Asian and 7 Caucasian subjects underwent 1–3 AFP treatments using a scanned 250 μm CO2 laser beam for the indications of scar reduction (n = 42), skin tightening (n = 32), enlarged pores (n = 6) and others (n = 5). Two patients were treated for both acneiform scars of the face and atrophic scars on the neck so that in summary, 87 treatment sites received laser therapy. Post-treatment erythema (redness) and edema (swelling) as well as overall satisfaction were graded on a quartile scale with scores from 0 to 3. All designated and observed side effects were noted by blinded observers. Results The patient satisfaction (scored by a blinded observer) after AFP for scar reduction, skin tightening, and enlarged pores ranged from minimal to marked clinical improvement with a tendency for a better outcome after repeated treatments. Erythema and edema lasted for 1–4 days in all patients and only one patient developed post inflammatory hyperpigmentation (PIH) after the first treatment. Conclusion The presented results allow the conclusion that AFP performed by a scanned CO2 laser is a safe and effective treatment modality for the improvement of rhytides and photodamaged skin, scarring, enlarged pores and hyperpigmentation in both Asian and Caucasian people, with a minor risk of dyspigmentation. Potential refinement of the number of sessions and treatment parameters need further evaluation to maximize the therapeutic efficacy for the different indications.

Selection and preference for botulinum toxins in the management of photoaging and facial lines: patient and physician considerations

Various noninvasive to minimally invasive techniques can be used for the improvement of cutaneous changes seen with photoaging. These include dermabrasion, chemical peels, ablative and nonablative lasers, and filler agents such as hyaluronic acid. However, the most common nonsurgical cosmetic procedure performed in the treatment of rhytides is injection with botulinum toxin. Its extensive safety history and relative ease of use by the practitioner has led to high satisfaction in millions of patients. Nonetheless, proper training of the fundamentals in injection technique, the choice of the appropriate candidate, and knowledge of potential adverse events are imperative to ensure a satisfactory and safe outcome.

Office Based Facial Plastic Procedures for Otolaryngologists

Program Description: The modern otolaryngologist has had residency-based, and in many cases, advanced fellowship training in a wide spectrum of facial plastic and reconstructive procedures to correct congenital-, acquired-, and aging-related deformities. Due to advances in technologies, there has been an increase in the ability to offer patients a variety of effective and minimally invasive interventions in the office setting. Among these interventions, the use of injected botulinum toxin has become common in the treatment of rhytids, hyperfunctional lines, and facial dystonias. The treatment of skin and subcutaneous contour deformities is also a common challenge for which patients seek consultation. Although previously the materials used for correction were limited in number, there has now been an increasing number of widely used and newly introduced materials made available to the practitioner. The introduction of hyaluronic acid–based agents created a significant increase in acceptance and demand for f...

A predictive model of minimally invasive bipolar fractional radiofrequency skin treatment

A novel bipolar fractional radiofrequency (FRF) system with temperature feedback was recently developed for facial laxity and rhytid treatment. The study objective was to develop a model based on published in vivo human skin data that could be extrapolated to aid physicians in making future dosimetry choices under clinically relevant conditions. A standard electrode pair designed for use with the FRF system was modeled using finite element analysis (FEA). The model incorporated temperature feedback from sensors within the electrodes, selectable target dermal temperatures, and an epidermal cooling plate. The model was validated using data obtained during clinical treatments. Thermal injury as a function of target temperatures and electrical conductivity was simulated and then validated using in vivo histology results. Lesion size predicted by the model matched histology samples. Lesion width and height were 1.65 and 1.24 mm compared to 1.75 and 1.21 mm for the model versus in vivo, respectively. The thermal profile remained confined between the proximal and distal ends of the electrodes. Ninety-six percent of power was deposited in the dermis. Dose-response curves showed a nonlinear volume increase to 1.7 and 4.7 mm(3) at target temperatures of 65 and 75 degrees C, respectively, and a low sensitivity to electrical conductivity variation. FEA of the Bipolar FRF system revealed that isotherms were mainly within the dermis. Lesion volume was found to be less sensitive to changes in electrical conductivity than to target temperature and duration. Simulation results matched well the in vivo lesion dimensions. To our knowledge, this is the first model of bipolar FRF treatment capable of accurately predicting the thermal response of human skin in vivo. The findings of this study allow for the development of accurate dose-response curves to aid physicians in parameter selection and achieving efficacy and safety profiles.

Reply

Sir: We thank Dr. Azizzadeh for the comments on the article “Late-Onset Infections and Granuloma Formation after Facial Polylactic Acid (New-Fill) Injections in Women Who Are Heavy Smokers.”1 We would like to address the issues presented by Dr. Azizzadeh. First, New-Fill has been in use for a variety of indications, including correction of human immunodeficiency virus lipodystrophy and lip atrophy, in addition to the common cosmetic indications for treatment of rhytides. We described granuloma formation with palpable nodules at the nasolabial folds after correction of rhytides (one of the principal indications for cosmetic use of New-Fill). In addition, we described a similar phenomenon at the lip vermilion when the New-Fill filler was injected to correct lip atrophy. In our view, the place of injection is not the main issue and was not part of our considerations. Second, we would like to mention that all of the patients were injected in different outpatient clinics and all of the patients were referred to our treatment after frustration with their physician’s failure to provide a satisfactory solution. Third, there are prior descriptions of adverse events after injections of New-Fill2,3; our experience was not unique. We must not forget that those women underwent a series of unpleasant treatments before their referral. Fourth, the late onset of the adverse effects described in our article suggests that granuloma formation and especially infection are not technique related. Although nodule formation is a well-known consequence of soft-tissue augmentation, not all dermal fillers cause this undesired effect and therefore may be preferred. Finally, our article is a case presentation depicting adverse events after filler injection. We may only suggest causality with smoking, but further research is necessary to establish it. Nevertheless, our center is a tertiary referral center, and we have seen more smokers with New-Fill late complications compared with other fillers. Oren Goldan, M.D. Gil Grabov-Nardini, M.D. Department of Plastic and Reconstructive Surgery Sheba Medical Center Ramat Gan, Israel

A novel radiofrequency device for the treatment of rhytides and lax skin: A pilot study

Background: Radiofrequency devices generate electromagnetic energy to induce dermal heating to a critical temperature of about 65°C, causing collagen to shrink and contract, and this provides a non‐ablative means to improve rhytides and lax skin. Objective: To evaluate the efficacy and safety of a novel radiofrequency device (Photo Bio Care, Thailand) operating at a frequency of 1.75 MHz for the treatment of rhytides and lax skin in Asian patients. Methods: Six female patients (age range, 30–60 years; mean age 48 years) with class I and II facial rhytides and Fitzpatrick skin types III and IV were treated six times at intervals of 2–3 weeks. The forehead, periorbital area, cheeks and nasolabial folds were treated using the following parameters: monopolar mode, pulse duration of 5 s, frequency of 18 Hz, and power of 100 W. No preoperative anesthesia or postoperative treatment were used. The handpiece was applied to the skin in a continuous sweeping motion until the baseline skin temperature was elevated to 40°C, as monitored with a laser thermometer, and this was maintained for 3 minutes. Clinical photographs were taken before, after the sixth treatment and 2 months after the last treatment. Analysis was undertaken through photographic evaluation by non‐treating physicians. Results: At 2 months after the last treatment, mild to moderate (25–50%) clinical improvement was noted in all patients compared to baseline, and all patients were somewhat satisfied with the treatment. The procedure was well tolerated with no unexpected side effects. Discomfort was rated as mild and post‐treatment erythema resolved within 1–2 hours. Conclusion: Treatment with the radiofrequency device can result in mild to moderate clinical improvement of age‐related rhytides and lax skin. The system is safe and inexpensive with no consumables required.

Thermage: the nonablative radiofrequency for rejuvenation

Thermage is a noninvasive nonablative device that uses monopolar radiofrequency energy to bulk heat underlying skin while protecting the epidermis to produce skin tightening. It is used for the treatment of rhytids on the face including the periorbital region and lower face, and more recently, for off-face applications. Studies have shown that it can impart mild tightening of periorbital mid, and lower facial laxity. Other radiofrequency devices have also shown objective improvements in cellulite of the buttocks and thigh regions. Thermage is an efficacious and safe nonsurgical alternative for treating mild skin laxity.

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

Previous studies have shown that radiofrequency (RF) energy is a safe and effective treatment for rhytide-reduction. This randomized, blinded, split-face study assesses the safety and efficacy of the unipolar versus bipolar handpieces on an RF device with a mobile delivery method for the treatment of rhytides and laxity using quantitative grading. In this randomized, blinded, split-face design study, 10 subjects (aged 18-75 years) with a clinically observable excess of rhytides and laxity (minimum grade 2 out of 4) on the face received four treatments at 1-week intervals with random assignment of unipolar RF to one side and bipolar RF to the contralateral side. Each side received approximately four passes per treatment delivered in a mobile continuous manner. Results were evaluated by two blinded investigators of photographs employing a comprehensive 4-point grading scale at baseline, and 1- and 3-month follow-up visits after the final treatment. All subjects completed and responded to treatment. The blinded evaluations demonstrated the following mean percent improvements in grading scores of rhytides and laxity: for the unipolar side 6.0+/-4.6% and 4.6+/-4.8% versus the bipolar side 4.4+/-2.5 and 7.3+/-3.5%. The degree of improvement approached but did not achieve statistical significance for either handpiece, but demonstrated a trend toward improvement (P = 0.5599 unipolar vs. 0.1108 bipolar). The treatment was painless (rated 0 out of 10 by all subjects) and side effects included minimal erythema which resolved within 1-3 hours. No crusting, dyspigmentation or scarring was observed. This randomized, split-face study with blinded evaluations employing a quantitative grading scale demonstrated that minimal pass, mobile energy delivery serial treatments with either the unipolar or bipolar handpieces of a novel RF device appears to safe and painless. Each handpiece demonstrated minimal clinical efficacy which was not statistically significant, but with a trend toward improvement in rhytides and laxity of facial skin.

Advances in plasma skin regeneration

Plasma skin regeneration (PSR) is a novel method of resurfacing that uses plasma energy to create a thermal effect on the skin. PSR is different from lasers, light sources, and ablative lasers in that it is not chromophore dependent and does not vaporize tissue, but leaves a layer of intact, desiccated epidermis that acts as a natural biologic dressing and promotes wound healing and rapid recovery. Histological studies performed on plasma resurfacing patients have confirmed continued collagen production, reduction of elastosis, and progressive skin rejuvenation beyond 1 year after treatment. PSR has received US Food and Drug Administration 510 (k) clearance for treatment of rhytides of the body, superficial skin lesions, actinic keratoses, viral papillomata, and seborrheic keratoses. PSR also has beneficial effects in the treatment of other conditions including dyschromias, photoaging, skin laxity, and acne scars. The safety profile of PSR is excellent, and there have been no reports of demarcation lines in perioral, periorbital, or jawline areas, as can sometimes be observed following CO2 resurfacing. PSR is effective in improving facial and periorbital rhytides and can be used on nonfacial sites, including the hands, neck, and chest. Numerous treatment protocols with variable energy settings allow for individualized treatments and provide the operator with fine control over the degree of injury and length of subsequent recovery time.

Effect of fluence on efficacy using the 1440 nm laser with CAP technology for the treatment of rhytids

The objective of this study was to evaluate the effect of fluence on the treatment of rhytids using a 1440 nm laser with CAP(SM) technology and the T350 tip. Twelve subjects with rhytids were enrolled in an IRB approved study. The Affirm laser with CAP technology (Cynosure, Inc., Westford, MA) 1440 nm, 10 mm T350, 2 milliseconds, 1.5 Hz was used at fluences ranging from 3.0 to 5.5 J/cm(2) in a split face study. At each treatment visit, fluences on the right side of the face were held constant at 3.0 J/cm(2), while the left side of the face started at 3.0 J/cm(2) and increased 0.5 J/cm(2) with each treatment to a maximum of 5.5 J/cm(2). Five treatments were given at 2-week intervals using the SmartCool (Cynosure, Inc.). Photographic comparisons at baseline and 3 months were used to compare fluence results as well as to evaluate for efficacy in the treatment of rhytids. The following standard scale was employed: Poor (0-25%), Fair (26-50%), Good (51-75%), and Excellent (76-100%). In addition, following the study, a few subjects received a series of laser pulses at increasing fluences on their buttocks to further evaluate the effect of fluence on tissue reaction. Comparing the right and left photographic results, no clinically observable differences were noted. Both sides received the same grade in all cases. Five subjects (42%) were noted to have Good results, three (25%) were given a rating of Fair, and four (33%) were given a Poor result with little or no improvement observed. The follow-up buttock fluence study demonstrated an effect threshold at 3.0 J/cm(2). The 1440 nm laser with CAP technology can provide overall improvement in patients with rhytids at moderate fluences. Increasing the fluence does not appear to increase efficacy.