Dr. Kono

The study was performed at the Tokyo Women's Medical University, Tokyo, where Dr. Kono is chief of the laser unit and assistant professor, department of plastic and reconstructive surgery. It enrolled 16 patients with Fitzpatrick skin types III to IV. Seven patients were treated with only the fractional 10,600 nm CO₂ laser (Fraxel re:pair, Solta Medical), six patients were treated with only the fractional 2,790 nm Er:YSGG laser (Pearl Fractional, Cutera), and the two lasers were used in a split-face comparison in three patients.

All patients received a single session of treatment. Settings for the fractional CO₂ laser were 40 mJ to 50 mJ for fluence with a density pattern of 8 (30 percent); for the Er:YSGG laser, the fluence was 160 mJ to 200 mJ and the density pattern was set at 4 (16 percent) or 5 (32 percent).

"A number of studies have investigated various fractional lasers for resurfacing procedures. In Asian patients, there is particular concern about the risk for postinflammatory hyperpigmentation (PIH), but there is little information about the relative efficacy and safety of different fractional lasers in this population. Comparative studies such as this can help to identify preferred treatment modalities and settings that can deliver the best results with the least complications," Dr. Kono says.

"Our study indicates the fractional CO₂ laser protocol we used is safe and effective for treating acne scars in Asian skin. However, it would be better to modify the parameters of the fractional Er:YSGG laser by reducing the density and/or fluence to minimize the adverse effects," he adds.

Dr. Kono also says patients did not use any bleaching agents pre- or postoperatively.

"Our longest follow-up was to six months. PIH improved over time, and particularly with the use of bleaching agents," he says.

DENSITY LEVELS Dr. Kono says the density levels for the two lasers were chosen so that they would result in similar coverage, and the individual energy levels were also selected so that the depth of penetration would be nearly the same for the two devices. However, the CO₂ laser uses a roller pattern while the Er:YSGG laser has a stamp pattern, and the CO₂ laser has a smaller spot size than the Er:YSGG laser — 120 microns versus 300 microns, respectively.

"The relatively high-density treatment using a stamp pattern with the fractional Er:YSGG laser seems to increase the risk of hyperpigmentation, while the risk for developing the visible tiny holes in the skin after treatment with the Er:YSGG laser may be attributed to the combination of the relatively high energy with a larger spot size," Dr. Kono says.

All of the procedures were performed using topical anesthesia (7 percent lidocaine cream) and with parallel air cooling (Zimmer Chiller, LaserMed). Ice packs were applied post-treatment, and all patients used an antibiotic ointment for postoperative care.

PATIENT RATINGS Patients were asked to rate treatment discomfort using a visual analogue scale (VAS) of 0 to 10. Despite the modalities used to improve tolerability, the VAS results showed that both laser procedures were moderately uncomfortable (mean VAS scores, CO₂ laser, 6.0; Er:YSGG laser, 6.3).

Patients initially returned for asses sment of healing at one week, and no difference was seen between groups in the time to recovery. Subsequent follow-up visits were conducted at one and three months post-treatment. Efficacy was judged by two blinded plastic surgeons based on their assessments of pre- and post-treatment standardized photographs (Visia CR, Canfield Scientific).

Disclosures:

NEW YORK — Home-use cosmetic treatment devices can be useful in achieving desired cosmetic outcomes, but they can be associated with adverse events, as well. Physicians and office staff must thoroughly educate patients on how to precisely operate the devices in order to avoid adverse events.

Dr. Sadick

"Home-use cosmetic devices are helpful, but are approximately 50 percent as effective as the similar office-based devices we use. This is because office-based devices are much more powerful, for obvious safety reasons," says Neil S. Sadick, M.D., F.A.C.P., department of dermatology, Weill Cornell Medical College, New York. "Nevertheless, patients are at risk of adverse events if they don't follow treatment protocols and use these devices inappropriately."

"If the company suggests using the device for a certain time period per treatment session and the patient erroneously uses the device for a longer period of time per treatment — either inadvertently or in the hopes of achieving a better and quicker cosmetic result — adverse events can arise," Dr. Sadick says.

Popular at-home devices include the no!no! Thermicon (Radiancy) epilation device, the new-generation red light HairMax LaserComb (Lexington International) for the promotion of hair regrowth and slowing of hair loss, and the Tanda Regenerate (Pharos Life) device for acne and photorejuvenation.

In order to achieve similar aesthetic outcomes as those with office-based technology, Dr. Sadick says at-home devices typically require more treatments, and treatments must be performed more frequently. Most home-use devices require an average of eight to 10 sessions, whereas in the office, the same cosmetic outcome can be achieved in four to five treatments. Depending on the technology, home-use devices must be used between two and four times a week for approximately three to four minutes each time.

ADVERSE EVENTS According to Dr. Sadick, the same adverse events that can occur with office-based devices can also occur with home-use devices. These can include first- and second-degree burns and, because these devices are light sources, blurred vision if the devices are not used as directed. Many of the home-use cosmetic treatment devices are sold over the counter, and most come with a CD explaining how to operate them. Most also include the manufacturer's suggested treatment regimens.

"We encourage the merchants who sell these devices over the counter not only to educate the consumer in how to operate the device, but also for them to explain to would-be users the importance of sticking to the suggested treatment protocols for each device. Here in the office, we also have our aestheticians or nursing staff educate our patients (on) how to operate a given device safely and effectively," Dr. Sadick explains.

REALISTIC EXPECTATIONS Home-use cosmetic treatment devices can be useful for patients who prefer not to visit the doctor very often and for those who would rather perform treatments in the comfort of their home. Some cosmetic patients will use these devices as maintenance programs, but, according to Dr. Sadick, the majority of patients use them to become accustomed to cosmetic treatments performed by the physician.

"When patients begin to use these cosmetic technologies at home, it is important that they have realistic expectations in terms of their aesthetic goals. If someone wants to lose all their hair, there is probably not a good home-use light source technology that can achieve that. These patients would require supplement treatments with office-based devices," Dr. Sadick says.

"Physicians should increase their awareness about home-use cosmetic technologies, because more and more patients are going to utilize them. These devices should not be feared, but instead, they should be thought about as an entrance point into your practice, or as a tool that can augment the results that you are able to achieve in the office, which will ultimately increase patient satisfaction," Dr. Sadick says.

DISCLOSURES:

Dr. Almeida

Outcomes were analyzed for a series of 45 Brazilian patients who underwent fractional photothermolysis using the 10,600 nm UltraPulse laser (Lumenis). All patients had Fitzpatrick skin types ranging from III to V, and the treatments were performed using the manufacturer's standard protocol. Outcomes were assessed subjectively by the patients and by four physicians who compared pre- and post-treatment 3-D, high-resolution photographic images (VECTRA 3D, Canfield).

The results from the patient and physician assessments showed all patients achieved at least greater than 50 percent improvement, and the majority improved greater than 75 percent. While all patients developed postinflammatory hyperpigmentation (PIH), it was generally mild and transient, and even patients who had more persistent PIH or other complications were highly satisfied with the results of their treatment. Another 40 patients have been treated with similarly favorable results, says Dr. Almeida, Sirio-Libanes Hospital, São Paulo, Brazil.

"Although all of our patients developed PIH, it was generally mild and in no case persisted longer than four months," he says. "However, further studies may be warranted investigating lower energy and density settings to see if pigmentary changes can be avoided, and at this meeting (ASLMS) we are also reporting a new method using only DeepFX with low densities without a single case of PIH."

PIH AND DARKER SKIN Photodamage is a common problem among Brazilians where sun exposure is high year-round, but dark skin types are also prevalent within the population, raising the concern of post-treatment pigmentary changes following laser rejuvenation. Researching the literature, Dr. Almeida and colleagues found that previous studies reported a lower incidence of PIH in patients with darker skin types treated with fractional CO₂ lasers, ranging between 0 and 37 percent.

Baseline (left), after 10 days of TotalFX (middle) and after 24 months of TotalFX, recorded with VECTRA 3D. This patient had a phototype IV skin type, with clinical indication of acne scarring and photoaging skin and intense, long-term PIH. (Photos credit: Guilherme Almeida, M.D.)

The fractional laser procedures were performed under IV anesthesia/sedation using propofol, in most cases. All patients were treated with antimicrobial drugs to prevent viral, fungal and bacterial infections, and with topical hydroquinone to minimize PIH. Patients were excluded from treatment if they had any active infection, history of keloid scar formation, were pregnant, had undergone chemical peeling or other cosmetic surgical procedures within the previous six months, or had used isotretinoin within the previous 12 months. Patients were also asked to withhold any medications or supplements with anticoagulant properties for one week prior to the laser treatment in order to minimize pinpoint bleeding.

TREATMENT PROTOCOL The treatment protocol consisted of a single pass over scars and rhytids using the DeepFX mode at an energy level of 5 mJ to 25 mJ, pattern 1-4, size 2, and density 2-3, followed by a full-face single pass with the less aggressive ActiveFX mode at an energy level of 70 mJ to 125 mJ, 150 Hz, pattern 3, size 2-5, density 2-3 in a vectorial fashion over the lax skin.

All patients developed erythema, edema, oozing and crusting post-treatment, but these sequelae all resolved within seven to 10 days post-treatment.

Post-treatment improvement was assessed at one and three months using a quartile rating scale where 1 = minor improvement (1 percent to 25 percent) and 4 = very significant improvement (76 percent to 100 percent). The physicians' assessments showed 36 (80 percent) of the 45 patients achieved very significant improvement, while the remaining nine (20 percent) achieved marked improvement from baseline.

The patient ratings showed they were even more pleased with their outcomes than were the physicians. Forty patients (89 percent) rated their improvement as very significant, and the other five (11 percent) felt it was in the marked range.

A severity rating scale of 0 (none) to 4 (severe) was used to assess PIH. Forty-two patients were seen seven days post-treatment; 30 patients had a PIH score of 1, six patients had a score of 2, five were rated 3 and only one patient had a severity score of 4. PIH had resolved in all patients by four months.

Other complications included late-onset hypopigmentation and hypertrophic scarring on the neck, each affecting only one patient. Both events were categorized as mild.

Disclosures:

The population of people with pigmented skin is growing in the United States, and, not surprisingly, cosmetic surgeons are interested in satisfying the anti-aging demands of this burgeoning market. Soft-tissue dermal fillers are the top guns in the quest for rejuvenation in these darker-skinned individuals, say cosmetic surgeons whose patients represent a diverse mix of ethnic backgrounds.

"If you look at a 70-year-old Caucasian woman and her 70-year-old black counterpart, they are strikingly different," says Washington cosmetic surgeon Cheryl Burgess, M.D. These differences dictate the tools Dr. Burgess chooses to restore a more youthful countenance.

A Hispanic patient in her 30s before (left) and after filler treatment that consisted of two syringes of Restylane (Medicis), one under each eye, and two syringes of Perlane (Medicis), one into each cheek and the chin. — (Photos credit: Sam Lam, M.D.)

Dr. Burgess

"I usually tell patients that they'll need three sessions, but I started noticing that when my black patients who are a skin type V or VI would return for their second session, there would be more thickening of the dermis in perhaps one out of four of them," Dr. Burgess says. Normally, she paces injectable filler sessions at about every four to six weeks, but in these patients she has modified the schedule to every six to eight weeks. "Histologically, the collagen bundles tend to be thicker in darker-skinned patients, and I think this is why the collagen is stimulated at probably a faster rate in some patients," Dr. Burgess says.

Dr. Burgess uses the same amount of filler in patients of color and in Caucasian patients and does not vary her injection technique or filler choice, but she is more conservative as far as the treatment schedule because of her anecdotal observation of ramped-up collagen stimulation. She recommends paying particular attention to the response of skin type V and VI patients after the first session, and then tailoring follow-up sessions based on their response.

"The most common cosmetic concern among my Asian patients is the fattening and widening of the face. Most patients are very satisfied with the use of fillers to restore the convexity of the cheeks and neuromodulators for narrowing and reshaping a widened jaw line," Dr. Burgess says.

'WOW' EFFECT Sam Lam, M.D., of Lam Facial Plastics in Dallas, likes to use injectables to subtly shape the face for a reinvigorating 'Wow' effect in his ethnic patients and patients of color. Dr. Lam points out that people of darker races sometimes have a wider faces, and in cases like this he will use injectable fillers "to sculpt the face into a narrower shape by focusing more toward the anterior cheek and anterior chin."

Dr. Lam

One of the most important facets of using fillers in patients of color, specifically, and in ethnic patients, in general, is to be familiar with the physical distinctions in these groups, Dr. Lam says. For instance, Asian people tend to have rounder, wider faces, so they need a lot less product.

"You need to be very selective to avoid making them look too full," he says. "I think what's really important is that you understand culturally where a person comes from, because, for instance, if you don't do a lot of Asian patients and you assume that you should treat them the same way as a Caucasian patient, you might blow up their face when what they really need is just a drop here and there."

SENSITIVITY COUNTS Dr. Lam stresses that it's critical to be sensitive to cultural connotations in order to use fillers for a positive outcome. "For example, if an African American person requests fuller lips and they already have full lips, you may create an accentuated stereotypical lip," he points out. "In Polynesian and African patients, I tend to discourage lip augmentation, because it can result in an ethnic look without necessarily making them look more attractive." Dr. Lam says this is not a frequent request, but that it does occur. (Trends suggest that older black patients are requesting lip plumping in an effort to recapture their youthful look now that fuller lips are a fashionable choice.)

Another example of when cultural sensitivity is crucial, Dr. Lam says, is in the case of Korean female patients. "If you don't know that large malar bones in Koreans are considered a masculine and unfavorable feature, you might inadvertently enlarge this feature and make a patient very unhappy," he says.

An example of a common use for injectable fillers in ethnic patients in Dr. Lam's practice is reshaping the nose in Asian patients. "I will inject the bridge of the nose in Asian patients to make it higher and to create a bit more of a dorsum, but I avoid the tip, which is very resistant to injectable rhinoplasty," he says, adding that it's important not to oversimplify this procedure by simply thinking the goal is basically a larger nose. "If you are not careful, you could overly westernize the patient's face, or you could raise their bridge to the level that either their tip looks too small or their nose looks artificial. The bridge starts much lower on an Asian, and you have to be sensitive to that," he says.

Another noteworthy factor in using injectable fillers in patients of color is that there is a greater margin of error in patients who have thicker skin, and this tends to be the case in darker-skinned patients. "The thicker the skin, the easier to inject because you can inject a little less deeply and feel like you're not going to have as much risk profile compared to very, very thinned-skinned patients," Dr. Lam says.

DISCLOSURES:
Dr. Burgess is a trainer for Sculptra and is on the Sculptra advisory board. Dr. Lam reports no relevant financial interests.