Near Infrared Pulsed Light for Noninvasive Skin Tightening, Toning and Improvement in Texture

Ilan Karavani, M.D. Dermatologic and Cosmetic Surgeon, Antwerp, Belgium

ABSTRACT The unprecedented demand for skin rejuvenation treatments in recent years has led to the development of many techniques and technologies aimed at treating age-related skin imperfections. When performing non-ablative skin remodeling with near infrared lasers (1320nm and 1450nm), the dermis is selectively effected by two basic mechanisms 1) the targeting of discrete chromophores in the dermis or at the dermal-epidermal junction, or (2 the use of near-to-mid infrared wavelengths, where absorption of water is weak enough that relatively deep beam penetration is attainable. These near infrared lasers require active cooling means. However, because of their relatively high water absorption and limited penetration, dermal heating is ineffective with most near infrared lasers. Due to the risks involved, slow coverage rate and cost effectiveness, the need for new technologies for non-ablative skin tightening procedures has been increasing. The new ST (Skin Tightening) module for the Harmony platform by Alma Lasers Ltd. (Caesarea, Israel) represents a novel approach in the field of nonablative skin rejuvenation. The ST pulsed light technology operates in the near infrared (780-1000nm) wavelength range which allows both deep penetration and effective subdermal heating without the need for aggressive cooling. The ST handpiece is indicated for the treatment of lax skin and non-ablative skin tightening and remodeling procedures in the facial area. INTRODUCTION The unprecedented demand for skin rejuvenation treatments has led to the development of many techniques and technologies aimed at treating age-related skin imperfections. It can be claimed that the growing demand for less invasive procedures with short recuperation time or minimal downtime has paved the way for non-ablative techniques.1 Non-ablative skin rejuvenation encompasses a spectrum of noninvasive techniques where laser, pulsed light or radiofrequency technologies are used to induce controlled thermal heating to the dermis while at the same time protecting the epidermis with cooling. To achieve subdermal heating a host of infrared laser devices that target water such as 1320nm and 1450nm long pulse neodymium:yttrium-aluminum-garnet (Nd:YAG) have been introduced and used to accomplish noninvasive dermal heating via nonspecific heating. However, because of the relatively high water absorption with these lasers, combined with limited dermal penetration, deep dermal heating was found to be ineffective. Similarly, with pulsed light technologies in wavelengths between 1100-1800nm (where water absorption is relatively high), subdermal heating is done indirectly - partially by direct heating (epidermal) and partially by heat conduction (subdermal), a technique that requires aggressive epidermal cooling. It is worth noting that despite achieving appreciable clinical results, ablative lasers (Er:YAG, CO2) are not used for subdermal heating since most of the optical energy is absorbed strongly in the epidermis (which ablates the epidermis).2 The new ST (Skin Tightening) module for the Harmony platform by Alma Laser Ltd. (Caesarea, Israel) is an innovative (non-laser), pulsed light source in the near infrared spectrum indicated for deep dermal heating and non-ablative skin tightening and remodeling procedures. ST MODULE OVERVIEW The ST handpiece 780-1000nm (near infrared) has an ideal tissue optical window for the subdermal heating (connective tissue, proteins) and low water absorption in the epidermis. These conditions eliminate the need for aggressive epidermal cooling. The ST handpiece energy output can be set between 5 - 105 J/cm2 based on 3 different selectable time intervals: 5, 10 or 15 seconds. During each time interval, the repetition rate is kept at 3Hz. The large spot size (6.4cm2) allows large coverage and true investment of energy density for better penetration and predictable thermal effect. The handpiece is applied on the skin where it is kept stationary for the entire exposure time (5, 10, or 15 sec) and fluence conditions. The ST module joins the Harmony systems existing range of other pulsed light and laser modules.

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Fig. 1: The ST (Skin Tightening) Handpiece and the Harmony System.

DEEP DERMAL HEATING In the aesthetic arena, dermal heating can be achieved indirectly via a process referred to as non-ablative skin remodeling. In non-ablative skin remodeling, the dermis can be selectively affected by two basic mechanisms: by targeting discrete chromophores in the dermis or at the dermal-epidermal junction, or by using near-to-mid infrared wavelengths, where absorption of water is weak enough that relatively deep penetration is achievable. Key components to non-ablative skin remodeling are epidermal protection and proper selection of laser/light irradiation wavelength and energy to evoke the desired thermal response in the papillary and upper reticular dermis. These non-ablative modalities obviate the need for epidermal injury and promote the reorganization and prolifiration of important dermal structures to reverse photodamaged and lax skin via thermal or photochemical process. Heat is generated within the zone of optical penetration by direct absorption of optical energy. The heating decreases with tissue depth as absorption and scattering attenuate the incident beam. The 780-1000nm optical window of the ST handpiece allows deep penetration (~2.5mm) and deep dermal heating due to heat conduction and to low melanin and water absorption in the epidermal-dermal layers. The favorable penetration between 780-1000nm wavelengths means less dermal scattering and more effective heating. In contrast, the 1100-1800nm optical window used by others has less penetration (~1.0mm) and more water absorption, which means greater epidermal heating, and less dermal heating, a condition which necessitates the need for active cooling.

intervention of optical or thermal energy. The ST handpiece exerts its biological effect on the skin through two major mechanisms: 1) heat-induced collagen shrinkage and micro-thermal injury and; 2) dermal regeneration, repair (wound healing) and remodeling. Collagen cleavage in tissue is a probability event dependant on temperature. The in-vitro thermal cleavage of the hydrogen bond cross-links of tropocollagen can result in the molecular contraction of the triple helix up to one third of its original length. Cellular contraction involves the initiation of an inflammatory/wound healing sequence that is perpetuated over several weeks. Contraction of skin is achieved through fibroblastic multiplication and contraction with the deposition of a static supporting matrix of nascent scar collagen. This cellular contraction process is a biological threshold event initiated by the degranulation of the mast cell that releases histamine. This histamine release initiates the inflammatory wound healing sequence. Following cellular contraction, collagen is laid down as a static supporting matrix in the tightened soft tissue structure. The deposition and subsequent remodeling of this nascent scar matrix provides the means to alter the consistency and geometry of soft tissue for aesthetic purposes. 4-6 TREATMENT PROTOCOL The ST handpiece is applied on the skin in a stationary mode. The practitioner places the handpiece on the skin for the entire exposure time and fluence conditions. To activate the handpiece, the operator should position the handpiece on the area to be treated and press the footswitch for the entire selected time interval. The handpiece will stop emitting light automatically unless interrupted by the operator (released footswitch). In order to continue, the footswitch must be re-pressed. Reposition the treatment head adjacent to treated area. An average of three non-sequential passes is given to a specific treatment area. Skin tightening patient candidates are typically younger patients who are not ready for surgery or are not surgical candidates. In addition, they may be older patients with mild to moderate laxity who do not want or are not candidates for surgery. The typical skin tightening, toning and texture smoothing patient does not want the expanse of surgical intervention or can not afford the downtime associated with surgery. Both the practitioner and the patient should identify and agree on the area to be treated. Marking the area may simplify the treatment process. Photography is recommended before and after the treatment to document the changes. Before initiating treatment, a Skin Test (single pass) on the intended treatment area should be done. After covering the area with thin (<1mm) layer of ultrasonic gel, the practitioner should place the handpiece on 3 different predetermined testing areas (adjacent) according to the recommended

Fig, 2 The optical penetration depth of light into the skin in the wavelength range from 400-2000nm (ref. 3) (Note the relatively deeper penetration of the 780-100nm wavelengths). MECHANISM OF ACTION: ST HANDPIECE Skin remodeling is a biophysical phenomenon that occurs at cellular and molecular levels via the

exposure conditions provided by the manufacturer. The Skin Test provides the patient and the practitioner feedback with the level of heat and the patients tolerance at given time exposure and fluence conditions. The patient should be able to tolerate the treatment with no more than moderate level of discomfort. The initial treatment conditions should be one that is well tolerated by the patient and will induce detectable thermal effect on the skin. During the treatment, the practitioner should monitor skin temperature using a laser thermometer until the endpoint of 39 - 42C epidermal temperature is reached (Fig 4). Sensitivity to the heat is a determining factor to stop treating at that level of treatment. Degree of discomfort is typically from none to mild to moderate. If the patient does not experience the sensation of heat or does not indicate that the temperature of the tissue is getting warmer, only up to 3 passes should be used as the maximum per treatment session.

nasolabial fold and chin staying below the check bone or malar fat pad. Tightening of the lower face lifts the fat pad. c) Over the orbital bone - pull down under eye skin, lower the fluence and treat under eye line making sure to avoid the intraocular region. d) Upper portion of the neck usually lower energy is required in this area. Individual variances occur but, in general, energy should be decreased by about 1 J per second and one pass should be eliminated. e) Under chin if fat pad is present, it may be of benefit to not decrease energy or passes to attempt some thermal modification. Following treatment, gently cleanse the treated area. If adverse skin effects occur (such as excessive reddening or swelling), exposure time or fluence must be reduced. After the treatment, the area should be cooled with chilled 4 x 4 gauzes for 5-10 minutes. Treatment intervals: treatment every 3-4 weeks for the facial/neck area. ST MODULE CASE-STUDY In order to evaluate objectively the efficacy of the ST handpiece for the treatment of aged-skin, a split-face study was conducted in which a 52 year-old female was treated on the right side, while the left side remained untreated (Fig. 5). The skin structure was examined with the SkinEvidence Visio (Laboratoires La Licorne, Grenoble, France), a biometrical device designed to capture a high definition digital image and subsequently to analyze the skin surface parameters such as length of the creases, total surface covered by the creases, roughness, and several indicators for the height and depth of the peaks. The direction of the creases is represented in a rose of distribution. The longer the red line in one direction, the more creases are aligned in that direction. Pictures of the skin surface on the treated side were taken before treatment and after the second treatment. The images of an identical zone were compared before and after treatment using the computerized analysis.

Fig. 4 Monitoring the epidermal temperature at the treatment area Before treatment, the treatment area should be cleaned to remove perfume, cosmetics and sunscreens. Any jewelry at the treatment area should be removed. In areas where hair exists, the hair must be shaved/trimmed. As in any other light-based procedure, appropriate eye protection (OD>5) goggles must be used by the patient and the medical staff. For better skin protection, apply a thin layer (<1mm) of transparent gel to the treatment area prior to treatment. The handpiece should be positioned perpendicular to the skin. The tip should gently touch the skin, avoiding any pressure. The number of passes (accumulative energy) can vary from patient to patient based on the size of the area to be treated. Skin tissue heating is patient and area specific and therefore should be monitored for each patient using laser thermometer when necessary). Treatment parameters may be increased by 10% every other treatment subject to the skin response and the patients tolerance. TREATMENT LOCATIONS a) Frontalis 1 cm above the brow line. b) Lower third of the face (jowls of face) beyond the

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Fig. 5 Split face comparison; right treated; left untreated.

Treatment protocol: First treatment: 7-11-05 5sec/15J/cm2/ no cooling; Second treatment : 7-25-05 5sec/35Jcm2/ Zimmer on 3 Treatment interval: 2 weeks

Harmony system for deep dermal heating allows even, uniform and predictable heating. Uniform heating reduces the chance of complications. Selecting optical power is straightforward and it is readily apparent on the Harmony systems user interface how much

Before Deduction from the above computerized analysis of the microstructure and the comparison of the figures before and after the treatment led to following observations: The rose of distribution shows a narrower alignment towards the main crease around 160 - 340, indicating the disappearance of the side branches after the treatment. The total length of the creases has diminished from 7.39 mm/mm to 6.75mm/mm (decrease of 10%), reducing the total creased surface by 4% The overall lighter color as seen by the RGB color code indicates a better reflection of the light due to a finer microstructure. The strongest indicators are the Maximum Profile Peak Height (Rp) (reduced from 84.7 GL to 59.74 GL), the Maximum Height (Rt) (reduced from 115.2 GL to 94.84 GL) and the Mean Spacing of Irregularities (Sm) (increased from 78.63m to 111.91 m). In conclusion, images and data analysis of the skin microstructures with the SkinEvidence Visio, support to the efficacy of the ST handpiece. SUMMARY The ST (Skin Tightening) handpiece is one of the Harmony platforms 10 different light and laser handpieces. In order to improve and widen clinical outcome for patients with age-related skin imperfections, the ST handpiece can be used synergistically with the 570nm (yellow-coded) AFT handpiece. Such combination therapy is recommended on the face and neck either before or after the ST treatment. The parameters of the AFT handpiece should be verified through a patch test just prior to full treatment. The ST module of the

After energy is being delivered. No single-use disposables are needed. REFERENCES 1. Kim KH and Geronemus RG. Nonablative laser and light therapies for skin rejuvenation. Arch Facial Plast Surg 2004;6:398-409. 2. Hardaway CA and Ross EV. Nonablative laser skin remodeling. Dermatologic Clinics. 2002;20:97-111. 3. Bashkatov AN et al. Optical properties of human skin, subcutaneous and mucous tissues in the wavelength range from 400 to 2000nm. J. Phys D: Appl Phys 2005;38:2543-2555. 4. Arnoczky SP and Aksan A. Thermal modification of connective tissues: basic science considerations and clinical implications. J Am Acad Orthop Surg 2000;8:305-313. 5. Nelson SJ. Majaron B, Kelly KM. What is nonablative photorejuvenation of human skin? Seminars Cutaneous Med and Surg 2002;4:238-250. 6. Lawrence WT. Physiology of the acute wound. Clinics Plast Surg 1998;25:321-337.