Skin Tightening
Nonablative therapies aim to deliver heat energy to the dermis (through the outer layer (epidermis) protected by cooling) to stimulate collagen remodeling to tighten skin. In this way skin tightening could be done without aggressive skin resurfacing.
The patient must have realistic expectations and preop photos taken. They should be made aware that changes are subtle. However, they are more natural and overcorrection are almost never seen. There are no scars or recovery period needed. For many this is a worthwhile option. There is a wide range of results possible including no results at all.
Patients wash their face thoroughly to remove all make up. Anchoring points are identified. Points are usually on the periphery of the face from where muscles pull up facial structures and skin. The operator stands in front of the patient and uses his thumbs to evaluate skin mobility. Skin next to the hair line is barely movable but moving toward the center of the face, the skin becomes more mobile. A treatment line is drawn at the border of movable and nonmovable skin. Movable skin up to that line is the target of treatment. Tightening of this skin can result in eyebrow lifting and softening the nasolabial fold. Lower eyelid sagging can be treated by treating near the anchor point just outside of the eye or by treating directly over eyelid skin. Treating skin just outside the lower eyelids over the cheeks is the safest. For lifting cheek skin to soften the nasolabialfold, treatment is done around the ears. The neck can be improved by treating under the chin.
The patients wash their face thoroughly. Treatment areas are marked. The skin needs no other prep. No topical anesthesia is needed for fluences less than 30J/cm2. Treatment areas are radiated in addition to other areas of loose sagging skin, including jowls and the neck. Immediate contraction can be seen in some cases. Total number of passes will vary. Each pass feels progressively hotter. The procedure is stopped if definite pain is noted. Complications include blistering or second degree burns. Fat atrophy has never been seen with this modality.
Treatment Summary: The BBL (Broad Band Light)
The proper combination of skin surface cooling and pulsed light treatment can create a beneficial rise in temperature at a desirable point below the skin surface. Cooling the surface of skin will alter its subsurface temperature gradient. The temperature of the BBL cooling plate and the fluence delivered from the BBL will determine the temperature profile beneath the surface of treated skin.
The epidermis is a robust and resilient structure at the surface. It functions as a physicial barrier to protect the deeper dermis, and retain the skin’s hydration. It is less hydrated than the dermis resulting in less absorption of energy at infrared wavelengths than in the dermis, since infrared energy is preferentially absorbed in water and collagen. The highest absorption, and thus the highest temperature, will occur below the epidermis in the more hydrated dermis. The result is a higher temperature near the region of the dermis. By clamping the outer skin surface at a fixed temperature with the BBL cooling plate, the peak temperature from laser treatment can be biased toward shallower or deeper regions of the skin.
An examination of the dermal anatomy will show that the papillary dermis is in contact and protrudes into the epidermis. It is therefore impossible to cool the epidermis without some cooling of the papillary dermis. Attempts to selectively pre-cool the epidermis by pulsed cooling followed by laser are equivalent to contact surface cooling with simultaneous laser treatment at the depths and times of interest for collagen remodeling.
The thermal profile in the skin will have a maximum temperature below the epidermis at a depth determined by the surface temperature and the absorption characteristics of the infrared pulsed light energy in tissue. It is thought that collagen strands are denatured and contract in response to high temperatures. The temperature for this effect is inversely proportional to the exposure time. Ideally, the peak temperature is just above the threshold for initiating collagen coagulation, but not enough to cause full thickness necrosis. By using long exposure times of several seconds and lower temperatures the risk of full thickness coagulation can be eliminated.
PRETREATMENT CONSIDERATIONS
Use a mild cleanser to remove any dirt, makeup, or moisture from the treatment area. Follow with an alcohol wipe. Allow alcohol to evaporate before treatment. Use special care around the eyes.
ANESTHESIA
Topical ansthetics are avoided in order to get the patient’s feedback on the heat associated with the treatment. A feeling of excessive heat will signal a need to change parameters or the end of the procedure. A coating of colorless gel will be placed on the patient’s skin to allow easy movement of the laser handpiece across the skin.
TREATMENT GOALS
The immediate goal is light, uniform erythema developing a few minutes after treatment. The longer term treatment goal, after 3 – 6 months, is collagen remodeling of partially denatured and contracted collagen resulting in subsequent rhytid (wrinkle) improvement and reduction of laxity, followed by continued or maintained improvement with a maintenance program. Patients will typically report felling tighter skin following treatment.
OBSERVATION
Erythema, a moderate sunburn sensation, and tightening should be noticed in the treatment area for up to two hours after treatment. Patients should not feel any significant discomfort after BBL/ST treatment.
INTERVENTION
While not often used, cold compress can provide some comfort after treatment. If blistering occurs, aggressive wound treatment should be administered like Vigilon, Second Skin, silastic sheeting or other intervention.
INTERVAL
Recommended time interval between treatments is 2-4 weeks. Dermal changes from fibroblast activity may begin to be observed between 3-6 months after treatment. Incremental improvement may progress for six months or longer. Tightness of the treated area may be noticed immediately after treatment. Usually, 2-3 treatment sessions are done. Remind patients that this is not a surgical process, collagen remodeling takes time, and that the results are long term.
CONCURRENT PROCEDURES
Rejuvenation treatments may be given in combination with other minimally invasive therapies. If a patient is to receive another treatment (light chemical peel, microdermabrasion, Botox, collagen injection) in conjunction with the BBL, it is advisable to perform the BBL treatment first. There may be increased sensitivity in the treated areas for an hour or two.
Nonablative therapies aim to deliver heat energy to the dermis (through the outer layer (epidermis) protected by cooling) to stimulate collagen remodeling to tighten skin. In this way skin tightening could be done without aggressive skin resurfacing.
The patient must have realistic expectations and preop photos taken. They should be made aware that changes are subtle. However, they are more natural and overcorrection are almost never seen. There are no scars or recovery period needed. For many this is a worthwhile option. There is a wide range of results possible including no results at all.
Patients wash their face thoroughly to remove all make up. Anchoring points are identified. Points are usually on the periphery of the face from where muscles pull up facial structures and skin. The operator stands in front of the patient and uses his thumbs to evaluate skin mobility. Skin next to the hair line is barely movable but moving toward the center of the face, the skin becomes more mobile. A treatment line is drawn at the border of movable and nonmovable skin. Movable skin up to that line is the target of treatment. Tightening of this skin can result in eyebrow lifting and softening the nasolabial fold. Lower eyelid sagging can be treated by treating near the anchor point just outside of the eye or by treating directly over eyelid skin. Treating skin just outside the lower eyelids over the cheeks is the safest. For lifting cheek skin to soften the nasolabialfold, treatment is done around the ears. The neck can be improved by treating under the chin.
The patients wash their face thoroughly. Treatment areas are marked. The skin needs no other prep. No topical anesthesia is needed for fluences less than 30J/cm2. Treatment areas are radiated in addition to other areas of loose sagging skin, including jowls and the neck. Immediate contraction can be seen in some cases. Total number of passes will vary. Each pass feels progressively hotter. The procedure is stopped if definite pain is noted. Complications include blistering or second degree burns. Fat atrophy has never been seen with this modality.
Treatment Summary: The BBL (Broad Band Light)
The proper combination of skin surface cooling and pulsed light treatment can create a beneficial rise in temperature at a desirable point below the skin surface. Cooling the surface of skin will alter its subsurface temperature gradient. The temperature of the BBL cooling plate and the fluence delivered from the BBL will determine the temperature profile beneath the surface of treated skin.
The epidermis is a robust and resilient structure at the surface. It functions as a physicial barrier to protect the deeper dermis, and retain the skin’s hydration. It is less hydrated than the dermis resulting in less absorption of energy at infrared wavelengths than in the dermis, since infrared energy is preferentially absorbed in water and collagen. The highest absorption, and thus the highest temperature, will occur below the epidermis in the more hydrated dermis. The result is a higher temperature near the region of the dermis. By clamping the outer skin surface at a fixed temperature with the BBL cooling plate, the peak temperature from laser treatment can be biased toward shallower or deeper regions of the skin.
An examination of the dermal anatomy will show that the papillary dermis is in contact and protrudes into the epidermis. It is therefore impossible to cool the epidermis without some cooling of the papillary dermis. Attempts to selectively pre-cool the epidermis by pulsed cooling followed by laser are equivalent to contact surface cooling with simultaneous laser treatment at the depths and times of interest for collagen remodeling.
The thermal profile in the skin will have a maximum temperature below the epidermis at a depth determined by the surface temperature and the absorption characteristics of the infrared pulsed light energy in tissue. It is thought that collagen strands are denatured and contract in response to high temperatures. The temperature for this effect is inversely proportional to the exposure time. Ideally, the peak temperature is just above the threshold for initiating collagen coagulation, but not enough to cause full thickness necrosis. By using long exposure times of several seconds and lower temperatures the risk of full thickness coagulation can be eliminated.
PRETREATMENT CONSIDERATIONS
Use a mild cleanser to remove any dirt, makeup, or moisture from the treatment area. Follow with an alcohol wipe. Allow alcohol to evaporate before treatment. Use special care around the eyes.
ANESTHESIA
Topical ansthetics are avoided in order to get the patient’s feedback on the heat associated with the treatment. A feeling of excessive heat will signal a need to change parameters or the end of the procedure. A coating of colorless gel will be placed on the patient’s skin to allow easy movement of the laser handpiece across the skin.
TREATMENT GOALS
The immediate goal is light, uniform erythema developing a few minutes after treatment. The longer term treatment goal, after 3 – 6 months, is collagen remodeling of partially denatured and contracted collagen resulting in subsequent rhytid (wrinkle) improvement and reduction of laxity, followed by continued or maintained improvement with a maintenance program. Patients will typically report felling tighter skin following treatment.
OBSERVATION
Erythema, a moderate sunburn sensation, and tightening should be noticed in the treatment area for up to two hours after treatment. Patients should not feel any significant discomfort after BBL/ST treatment.
INTERVENTION
While not often used, cold compress can provide some comfort after treatment. If blistering occurs, aggressive wound treatment should be administered like Vigilon, Second Skin, silastic sheeting or other intervention.
INTERVAL
Recommended time interval between treatments is 2-4 weeks. Dermal changes from fibroblast activity may begin to be observed between 3-6 months after treatment. Incremental improvement may progress for six months or longer. Tightness of the treated area may be noticed immediately after treatment. Usually, 2-3 treatment sessions are done. Remind patients that this is not a surgical process, collagen remodeling takes time, and that the results are long term.
CONCURRENT PROCEDURES
Rejuvenation treatments may be given in combination with other minimally invasive therapies. If a patient is to receive another treatment (light chemical peel, microdermabrasion, Botox, collagen injection) in conjunction with the BBL, it is advisable to perform the BBL treatment first. There may be increased sensitivity in the treated areas for an hour or two.
No comments:
Post a Comment