Debbie Thomas explores the use of combined laser technologies to achieve less irritation and reduced recovery time when performing ablative treatments
Background and objective: To determine the effectiveness of sequential laser-layering techniques (combined Nd:YAG and Er:YAG) to achieve optimal results in a shorter period of time whilst reducing downtime.
Materials and methods: Treatments were carried out on 10 patients (nine females and one male – six facial treatments only, and four face and neck treatments) with varying degrees of skin concerns, from open pores to loss of elasticity, and some fine lines and wrinkles. A combined Nd:YAG 1,064nm and Er:YAG 2,940nm device was used. Each patient had four treatments at two to three weekly intervals.
Results: A significant improvement of the skin’s tone, texture and elasticity was noticed by the patients themselves and was visible in photographs. Best results can be seen approximately 8-10 weeks after the final treatment.
Conclusion: This combined laser method allows for a very bespoke skin remodelling treatment, which gives results comparable with stronger ablative peels, with several days less recovery time. Patients were pleased with the results and said that they would be happy to continue with treatments to further enhance the skin and maintain results.
Common problems we face today are patient’s expectations versus their willingness to go through an extended period of recovery time. Reducing the strength of the treatment to achieve a more manageable recovery time often leads to a less than satisfactory end result for patients. Studies have shown that the most effective way to balance this is to combine different laser technologies, at lower levels, within one single treatment.1,2,3 Optimum results can be achieved as one technology enhances the results of the other. An excellent example of this is combining Nd:YAG bulk heating and Er:YAG cold fractional ablation in a multi-step procedure, optimised to improve skin tone, texture and colour. It is a gentle alternative for treating fine lines, wrinkles, mild scaring and open pores with minimal downtime and natural results.
Materials and methods
Patients: 10 patients of Fitzpatrick skin types II-III, affected by mild photo- and chrono-ageing (aged between 36-60 years, with a mean age of 44) were used in our study. Nine females were treated on either their face, or face and neck, and one male was treated on the upper-face, avoiding the beard area. Patients were informed of, and discussed, treatment protocols and their consent for treatment was obtained.
Equipment: Nd:YAG (1,064nm) and Er:YAG (2,940nm) laser lights (the SP Dynamis from Fotona) was used in the study protocol. The Nd:YAG was used in full-beam bulk heating and fractional modalities using a scanner, whilst the Er:YAG was used in ablative and non-ablative fractional mode scanner, with the hand piece used.
Older ablative skin rejuvenation procedures would either treat large areas of the skin with full-beam ablation, or need a considerable amount of heat in fractional mode to achieve desired results – both of these methods result in a recovery time of 5-14 days. I have been using a two to four step method, which significantly reduces patient’s recovery time down to two to four days – without compromising results – making it a viable option for time-sensitive patients. We understand that heat is a key component in stimulating neo-collagen and extracellular matrix production when properly administered in different skin layers. Thus, using the full-beam bulk heating Nd:YAG laser for deep heating and the fractional Nd:YAG for selective heating, combined with the superficial peeling preformed with the Er:YAG, covers all skin layers and should give excellent results. A topical anaesthetic, that contains the two active ingredients lidocaine and prilocaine, was used on all patients 40 minutes prior to treatment and was covered with an occlusive dressing. Patients were first treated with two passes of short (1.0 ms-35 J/ cm2-scanner operated 6 mm) 1,064nm Nd:YAG laser and one pass of long (50 ms-50 J/cm2 scanner-operated 6 mm spot) 1,064nm Nd:YAG laser. This conditions the skin and bulk heats the area to stimulate deep collagen remodelling, enhancing overall healing and rejuvenation of the skin.
Immediately following this is one pass of 2,940nm Er:YAG laser in fractional mode (short pulse – 8 J/cm2- 0.25 mm spot-5% ablated area-scanner). The short pulse, mild Er:YAG treatment allows for cold ablation of the skin, meaning there is minimal down time and short recovery time for the patient. Finally a pass of non-ablative fractional 2,940nm Er:YAG (a long pulse-4.2jcm2-12mm-fractional hand piece) has a thermal effect on the surface of the skin – achieving excellent skin tightening.
During the treatment the entire area being treated was covered by each laser modality in sequence. For all Nd:YAG treatments, a scanner is used with a 6mm spot-size and a 5% overlap. The area to be scanned can be changed from a 6mm spot to a 6cmx6cm square – this gives a very even and consistent treatment. The fractional Nd:YAG modality allows for a deep but controlled 3D thermal effect that seeks out imperfections within the skin. Targeting only the imperfections allows for a much safer treatment that is very well tolerated by the skin. The full-beam Nd:YAG modality has the deepest penetration and helps to build the required heat to trigger the skins ‘healing’ response. At this stage of the treatment you are looking to get a mild to moderate erythema. The combination of the two settings also helps to reduce post-treatment redness, as the lasers are commonly used on their own for anti-redness, skin strengthening and vascular lesions. The first pass of the Er:YAG is done using a scanner that can be adjusted from a 1mm spot to 1cm2. It can ablate between 5-20% of the tissue and uses a Variable Square Pulse (VSP) to perform a very clean and precise treatment. VSP technology generates square laser pulses for more controlled energy absorption.4 Pulse durations can be adjusted from 50us up to 1,500us, depending on the strength of peel required. VSP pulse technology minimizes unnecessary laser energy absorption into body tissues and helps to ensure ultimate performance and patient comfort during laser treatments. For this treatment I set the scanner to 5% ablation, a short pulse (600nsec), which produces minimal heat and a low energy, as I only require a light peel. On its own this setting would be considered a very light, superficial treatment with minimal results.
Efficacy results on the face and neck varied between patients, however in each case there were visible improvements. Patients’ skin was more even in tone and texture, pigmentation issues were improved, pores were more refined and fine lines and redness was reduced.
Efficacy results on the face and neck varied between patients, however in each case there were visible improvements. Patients’ skin was more even in tone and texture, pigmentation issues were improved, pores were more refined and fine lines and redness were reduced. When asked to self assess, each patient verbally communicated happiness with the overall result and felt that the recovery time was manageable. The patients reported that within the first 12-24 hours the skin was tender and erythema was moderate to strong. There was no redness and only mild flaking of the skin for a further 24-72 hours. For the female patients Oxygenetix (breathable, post procedural make-up) was applied daily during this time and so patients felt happy to be out in public, without feeling self-conscious. For both the females and the male patient a post procedure SPF was used.
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