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Fractional Ablative Lasers and Micro-plasma Radiofrequency in Skin
Rejuvenation
Anti-Ageing Conference, London 2012
Maria Angelo-Khattar M.D., Ph.D.Aesthetica Clinic
Dubai
Life Expectancy Chart from 1850-2000
Strong Shift Towards Minimally-Invasive Procedures
Pre-1992 : Aesthetic Corrections were mainly Surgical
1992: Jean and Alistair Carruthers published the firstpaper on the Cosmetic Use of Botulinum Toxin
(Procedures in millions)
0.0
4.0
8.0
12.0
6.0
10.0
2.01.0M1.1M
1.9M
9.5M
1997 2006
Non‐
Invasive ProceduresInvasive Procedures
0.0
4.0
8.0
12.0(Procedures in millions)
6.0
10.0
2.0
1997 2006
Growth Rate = 98%
Growth Rate = 747%
Source: The American Society for Aesthetic Plastic Surgery, March 2007
Minimally-invasive procedures account for majority of growth Minimally-invasive procedure = 83% of market
Strong Shift Towards Minimally-Invasive Procedures
Tightening
Texture
Tone
Colour
Skin Refining with Ablative Fractional Lasers and Radio-frequency Devices
Courtesy of Aesthetica Clinic
P.J. 57 years old:Five
months post
vertical face lift
Aesthetic Treatments
Skin Care Regimen:-Sun protection-cosmeceuticals
Hormonal Optimisation
Avoidance and Elimination of toxins
Lifestyle:DietExerciseSleepStress controlRelationships
Nutrition and supplementation
ANTI
AGIN
G P
RIN
CIPL
ES
Keith RichardsThe Rolling Stones
Inhibit leucocyteelastase
Decrease elastin degradation
Increase elastindeposition
ELASTOSIS
PHOTO AGEING
Extrinsic AgeingUV exposure
Intrinsic AgeingOxidative Metabolism
Suppress TGF-BetaReceptor 2
Degrade antioxidants
Suppress pro collagensynthesis
REDUCTION IN DERMALCOLLAGEN LEVELS
Degrade collagen
Activate MMP
Active AP-1
Increase ROS
InduceInflammation
Activate NF-Kappa B
Dermal Atrophy and Loss of Normal Architecture • Impairment of the micro- circulation
• Cellular degradation: mainly fibroblasts
•Collagen fibre degradation via MMP-1 induction
- Loss of collagen integrity• Elastosis
-Loss of elasticity• Extra-cellular matrix degradation
•Subcutaneous fat resorption and redistribution
-Volume Loss
Collagen degradation: ‘young’ vs ‘old’
24 years old 48 years old
Elastica von Giesson staining
Elastosis: degeneration of elastin fibers
26 years old 66 years old
Specific immuno-elastin staining
Physical Aging is Optional
Keith Richards Born in 1943 Robert Redford Born in 1936
Who is the mother and who is the daughter?
What Characterises a Youthful Appearance?
Young Skin is Bright SkinA Young Face is Full Face
Skin Peels
Mesotherapy/ Microneedling
Fractional Ablative Laser Resurfacing
Non-Ablative Photo- Rejuvenation
Full Laser Resurfacing
Carbon Dioxide and Erbium YAG lasers
Effi
cacy
Skin Refinement and Rejuvenation: Basic strategy follows the principle of “Controlled
Wounding…”
Wound Healing ReactionWound Healing ReactionWound Healing Reaction
Injury
AntioxidantsRetinoic acid/ retinol
Retinoic acid/ retinol
Healing and remodeling of skin damaged by the effect of intrinsic aging, extrinsic aging, wound or laser procedures
Intrinsic AgeingOxidative Metabolism
Inflammation leading to ROS Mediated ECM Degradation
Wound
TGF BetaPDGFVEGFIGFFGF 2IL8
Laser Procedures
Intrinsic AgeingOxidative Metabolism
ECM Formation Woud ClosureRe-epithelialisation
Dermal Remodelling
TGF betaFGF 2TIMP’sMMP’s
Lasers and Energy Based Devices can ….
Improve the appearance of Aged Skin
Reverse the signs of Skin Aging
Delay Skin Aging
Reduce the risk of Skin Cancer?
Full Laser Skin Resurfacing
69 year old: before and after full face skin resurfacing Courtesy Dr. Susan M Hughes MD
Deep, partial-thickness skin resurfacing requires intensive topical therapy and may be characterized by the following risks:Acute:– Risk of surface yeast, viral and bacterial super-infection– Re-epithelialization in cases of superficial peels requires at least 8-10 days ,
in deep peels approximately 3 weeks.
Sub-Acute:- Patient remains erythematous for 6 weeks to 3 months and in some casespermanent redness may result.
Long term complications: – Permanent hyper-pigmentation, hypo-pigmentation and scarring may
occur. – Lines of demarcation– Sunlight hyper-sensitivity from half-year to a year.
Traditional Laser Resurfacing Complications
……requires downtime requires downtime
Must protect from sun exposure!Immediate and prolonged weeping, oozing, redness
Patients want results but no down-time!
From Bulk to Fractional
Introduction to Ablative Fractional Resurfacing
Creation of microscopic channels in the skin interspersed between normal tissue
DERMIS
EPIDERMIS
Ablative Fractional Resurfacing
Ablative Fractional Resurfacing Options
Fractional Ablative LASERS:Er: YAG Laser
CO2 Laser
Fractional Ablative Radiofrequency Plasma Technology
•• Ablation Ablation ––Vaporization shrinks the epidermisWhen the epidermis is ablated, there is a reduction of
dyschromia and even precancerous lesions
•• Thermal effectThermal effect –– heat the upper dermis promotes :heat the upper dermis promotes :
Denaturation of ExtraDenaturation of Extra--cellular matrix proteinscellular matrix proteins
Immediate contraction of collagen exposed to temperatures Immediate contraction of collagen exposed to temperatures above 60above 60oC
Deposition of new collagen Deposition of new collagen
Reorganisation of the dermisReorganisation of the dermis
Two Skin Renewal Mechanisms
Mechanism of Action of Ablative Fractional Resurfacing
Ablative Fractional LasersCO2 and Erbium:YAG lasers
Mechanism of Action
Relative Absorption of Er:YAG and CO2 lasers
CO210,600nm
Erbium is highly absorbed by waterAnd therefore the thermal injury Is lower than with CO2.
Erbium 2940nm
Laser Skin Interaction
Fractional CO² and Er: YAG work by applying the laser energy through holographic lenses that pixelate the beam to microscopic beams or pixels on the surface of the skin.
How are the CO2 and Er: YAG laser beams fractionated
Non-injured
Injured
Fractional Er: YAG Skin Manifestations
Lasers in Surgery & Medicine, March 2008
Moshe Lapidoth MD, MPH. Marina Emiko Yagima Odo, MD, Lilian Mayumi Odo.
Novel use of Erbium:YAG (2940 nm) laser for fractional ablative photothermolysis
in the treatment of photodamaged facial skinA pilot study
6-134Dermatol Surg, 2008
Publications
Mario A. Trelles & Serge Mordon & Mariano Velez &Fernando Urdiales & Jean Luc Levy Lasers Med Sci2008
Skin Before and Two months after a single treatment with Fractional Er:YAG
Ablative Unipolar Radiofrequency Plasma Technology
The treatment technique may be either Stationary and In-motion due to two separate handpieces
RF Application Technique
2. Transdermal drug delivery with Ultrasound hanpiece
1. Plasma Ablation with unipolar RF
Plasma
• Plasma state is the fourth state of matter• Plasma is a state of matter in which electrons are
stripped from atoms to form an ionized gas.
+
+
++
- +
+ +
+
-
-
-
--
- --
Solid
Liquid
Gas
Plasma
EnergyEnerg
y Energy
• The electromagnetic RF energy excites gases in the air such as nitrogen and produces Plasma, thus forming micro-sparks between the skin and the RF electrode.
• These sparks ablate and perforate the skin
• This produced micro-channels, their depth and diameter depend on duration of pulse of RF-energy and RF-power.
RF Energy
Plasma
Skin
Plasma Skin Interaction
RF Fractional Ablation results in Microscopic Ablated and Coagulated Tissue Channels
• Porcine Skin• Depth and diameter depend on Power and Pulse
duration– 100-150µm in depth and 80-120 µm in
diameter
Day 0 Day 3 Day 14
Photo Courtesy: Arie Orenshtein, M.D, Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel Hashomer, Israel
Pre-Clinical Studies
Ablative Fractional Skin Resurfacing Indications and Clinical Protocols
Improvement in Skin Surface Texture
Clearance of Photo-damaged skin/ Dyschromias
Reduction in Perioral and Periorbital rhytides
Reduction of Pore size
Post-acne scarring
Treatment of Surgical and Post traumatic
Clinical Indications
Contraindications
Dermatological Conditions: Dermatitis, AllergyHaving taken Isotretinoine within the past 6 months History of Cancer or Autoimmune DiseasePregnancyHistory of poor wound healing and keloid formationDemonstrate prolonged erythema, hyper- pigmentaion or hypo-pigmentation upon patch test
Patient Preparation
Emla cream with occlusion for fourty minutes
Nerve blocks
Infiltration anaesthesia
Post Treatment Sequelae
For 5-7 Days
Redness
Swelling
Crusting
Prolonged Erythema following aggressive treatments
Before Day 1 Day 2
Recovery Time Frame After Fractional Laser
Day 3 Day 4 Day 5
General Pre/ Post Treatment Care
1. Antiviral Medication: Valciclovir 1gm every 12 hours for one day
2. Topical Antibiotics: Fucidic acid cream twice daily for two days
3. Topical Steroid:
• 1% Hydrocortisone cream twice a day ( skin types IV, V and VI)
4. Depigmenting cream as of Day 4 for four weeks
1.Growth Factors: Platelet Rich Plasma and Proprietary growth factors
2.Vitamin C (10%) solution
3.Depigmenting Complex ( Arbutin, Retinyl Palmitate, Ascorbyl Palmitate, Azelaic acid, Phytic acid)
Trans Dermal Solutions
•A group of proteins that stimulate the growth of specific tissues.
•Some Growth Factors are similar to hormones in that they can be secreted into the blood stream and carried to target tissues.
•Growth Factors can be produced by many different tissues and cells in the body ( unlike hormones produced by glandular tissue). Can be produced by macrophages, platelets, fibroblasts, etc…)
•Chemical messengers between cells
•Turn a variety of cellular activities “on” and “off”
•Increase blood supply and cell recruitment
•Increase the rate at which cells in the body grow
•Involved in cell division, new cell and blood vessel growth and collagen and elastin production
What are Growth Factors?
Stem Cell Division and Differentiation
1. Growth FactorsAutologous Platelet Rich
Plasma
An autologous concentration of platelets in a small volume of plasma.
Number of Platelets in Whole blood is 200,000 / µl
Therapeutic enriched Platelet count is around 1,000,000 platelets/ µl . This concentration of platelets in a 5-ml volume of plasma is now recognized as being the working definition of therapeutic enriched Platelet rich plasma.
includes 3 proteins in blood known to act as cell adhesion molecules: fibrin, fibronectin & vitronectin
Clinical Uses: Plastic Surgery, Oral Surgery, Orthopaedic Surgery
What is Platelet Rich Plasma?
Contain growth factors
Contain serotonin, ADP and calcium
Platelet
– PDGF– TGF-b– VEGF– EGF– IGF– PF4– PDAF– Osteocalcin,osteonectin,
Fibrin, vitronectin, fibronectin and thrinombospondin
Platelet Derived Growth Factors
Increases fibroblast migration, proliferationPromote production of extracellular matrixPromote angiogenesisShown to enhance healing of chronic
wounds; shown to be absent/decreased in non-healing wounds
Pharmacological Action of Growth Factors
Action of Platelets at Injection Site
• Sterile closed System
• Enriched platelets 4- 5 times baseline concentration
Preparation of PRP using a proprietary kit
Centrifuged for 10 minutes at 3000 RPM
GEL
One tube yeilds approx. 6 ml of PRPOne tube yeilds approx. 6 ml of PRP
Preparation of PRP using a proprietary kit
Proprietary Growth Factors ( Fibroblast culture medium)