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Oral Maxillofacial Surg Clin N Am 16 (2004) 231 – 237

A brief overview of noninvasive lasers in cosmetic maxillofacial surgery
Derek K. Boyden, DDS
Olympic Surgical Associates, 450 South Kitsap Boulevard, Suite 2220, Port Orchard, WA 98366, USA

It has been said that the skin is a calendar by which the years can be measured. The search for and maintenance of aesthetic beauty is as ancient as human history [1]. In modern society, this quest may even border on intrusion. By simply observing almost any magazine, newspaper, or television program, we can appreciate the pervasiveness and ‘‘necessity’’ for beauty in our current culture. Advances have allowed surgeons to provide options to patients that were unheard of only a few years ago. Furthermore, today’s cosmetic consumer is savvier than in the past. The plethoric print, television, radio, and Internet information allows these patients to be better educated and aware of what options are available. Of paramount importance for any surgeon who specializes in aesthetics is the optimization of the patient’s skin appearance. Healthy skin will enhance the surgical result, whereas unhealthy, dyspigmented, wrinkled, rough, or irregular skin will detract from even the most exceptional surgical outcome. Contemporary oral and maxillofacial surgical practices encompass more than dentoalveolar procedures and endosseous implant placement. Today’s oral and maxillofacial surgeons are leaders in the evolution of elective cosmetic surgery, routinely performing facial cosmetic surgery, liposculpture, reconstruction, grafting, and augmentation. The advent of botulinum toxins, collagens, and hyaluronic acid injectable fillers is expanding the components of modern full-scope practices. Integral to these practices is skin care and skin enhancement. Through the use of pharmaceutic-grade skin care products, also known as cosmeceuticals or skinceuticals, patients

can improve not only the appearance of the skin but also its health. In conjunction with routine skin care, a number of noninvasive cosmetic laser procedures have become available to further improve the skin’s health and appearance.

Lasers and laser – tissue interactions The principle that any individual laser produces a unique wavelength of light energy is the key to cosmetic laser procedures. Choosing a laser that produces a unique wavelength allows for the targeting of a specific chromophore. Chromophores are any molecules (eg, water, melanin, hemoglobin) that preferentially absorb a given wavelength of the electromagnetic spectrum. Also of importance is the ability to avoid certain chromophores and to minimize undesirable absorption of energy. Another important component of laser – tissue interaction is the thermal relaxation time. This is the amount of time that a specific chromophore requires to dissipate one half of the heat generated by a laser pulse. The discovery and appreciation of the differing thermal relaxation times of different chromophores were critical steps forward in the use of noninvasive cosmetic lasers. By controlling the length of the laser pulse and by keeping it below the thermal relaxation time of specific chromophores, unwanted thermal damage to adjacent tissues could be minimized. Laser surgery essentially is the control of where and how much heat injury occurs to achieve a particular outcome (Table 1). There are certain physical properties unique to some devices that allow them to be used in a manner similar to a laser. In particular is the use of an

E-mail address: drboyden@olympicsurgical.com

1042-3699/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.coms.2004.02.006

light emission. diminish pore size. or evacuation of a laser plume. not all wrinkles are created equal. with permission. nonablative facial rejuvenation allows for more significant improvement. although pretreatment with a topical anesthetic may be used. Known by many different trade names depending on the type of laser used. in-phase. The development of newer products has led some investigators to examine how topical treatments affect and improve the skin’s physiologic makeup. and expressive rhytids. For example. Stated simply. Laser treatment of cutaneous vascular lesions. are believed to release inflammatory mediators through heating of the microvasculature.2 ms Adapted from Goldman MP. Nonablative skin rejuvenation Aging skin demonstrates many changes including increased laxity. textural irregularities. Lasers that target water produce nonspecific heating of the upper dermis. Although these defects may have a similar appearance. dyspigmentation. uniform. the treatment of all wrinkles cannot be approached in an identical fashion. The specific medium and techniques will vary between lasers. Lasers that target the hemoglobin chromophore. Therefore. 2nd edition. Fitzpatrick and Rostan [3] found that topical vitamin C used for 12 weeks resulted in a clinically visible improvement of facial wrinkles. achieve a younger. In: Cutaneous laser surgery.232 D. IPL has been used to treat numerous cosmetic conditions. Many of the options in a cosmetic surgery practice are directed primarily toward minimizing or eliminating facial wrinkles. and rhytids. improve skin texture. Due to the variety of wavelengths available (and subsequently. These methods are truly noninvasive and offer many advantages in an aesthetic maxillofacial practice setting. The lasing procedures are usually performed without anesthesia. solar-induced rhytids. The best cosmetic treatment plan may be one that uses multiple treatment options.K. 1). Louis (MO): Mosby. p. resulting in new collagen production and remodeling [4]. Fitzpatrick RE. St. These mediators may stimulate fibroblasts. For the purposes of this overview. There is no post-treatment ‘‘down time. The wavelength of an IPL ranges from 500 to 1200 nm and is selected by choosing one of a variety of interchangeable quartz filters. telangiectasias. Boyden / Oral Maxillofacial Surg Clin N Am 16 (2004) 231–237 Table 1 Thermal relaxation time of laser targets Target Basal layer Epidermis Erythrocyte Melanosome Approximate diameter (mm) 20 60 5 1 Thermal relaxation time 400 ms 2 ms 5 ms 0. Routine skin care is an important part of most presurgical protocols and equally important in nonsurgical regimens. intense pulsed light system (IPL). 1999. with the goal of stimulating new collagen production [5]. Postopera- . There is no need for wound closure. but for others. IPL lacks a single. 42. There are three general categories of rhytid classification: age-related rhytids. the principle of maintaining the tissue heating time below the tissue thermal relaxation time is universal. and ultimately. Many of the lasers used for noninvasive procedures use a cooling medium such as a gel or spray or use contact cooling to minimize epithelial heat damage.’’ Patients may present for treatment directly from their normal daily activities—even on their lunch breaks— and then return to work or other activities. Nd:YAG lasers stimulate the dermal and midreticular fibroblasts by thermal stimulation. Topical treatments may provide satisfactory improvement in some patients. they have been shown to have different histologic presentations [2]. in that the light emitted by this device is noncoherent. Rhytids are often the primary presentation for which patients seek cosmetic consultation. IPL is not a true laser. nonablative facial rejuvenation is designed to reduce facial rhytids. suction. IPL will be included with the true lasers. These clinical results were found to correlate with biopsy evidence of new collagen formation. Aging skin results from two distinct gross processes: intrinsic aging and photoaging (an indepth discussion of these extensively studied processes is beyond the scope of this article). healthier appearance (Fig. Many topical skin care products improve skin tone and texture. increased hair growth. however. such as pulsed dye lasers. the variety of chromophore targets).

The interval between treatments is 2 to 4 weeks.to 4-week intervals bring the lesions to resolution. By increasing the fluence to 16 J/cm2. The total time of a given treatment generally is less than 30 minutes. Boyden / Oral Maxillofacial Surg Clin N Am 16 (2004) 231–237 233 Fig. 3 weeks apart. Infraorbital hyperpigmentation The author successfully has used the following method of treating infraorbital hyperpigmentation or ‘‘dark circles’’ (Fig. At 1 week following the initial treatment. Anecdotally. further enhances the final outcome. Pretreatment (A) and 3 weeks following initial treatment (B) with Nd:YAG laser (13 J/ cm2. and 15. Fig. California) at 13 J/cm2 with a 5-mm spot size. Protective laser eyeshields or goggles are used. After 3 weeks.000 pulses each time).K. patients report improvement over the treated area. 5-mm spot size. and 3 to 5 treatments may be needed to achieve the desired results. 1. (Photograph property of Olympic Surgical Associates. the author found that patients with Fitzpatrick skin types III and IV tolerate many more pulses than patients with Fitzpatrick skin types I and II. Nonablative skin rejuvenation. and improved skin texture. and 400 pulses). 0. (Photograph property of Olympic Surgical Associates. patients received 750 to 1000 pulses bilaterally in the infraorbital region. The more pulses tolerated by the patient. diminished keratoses on right lip. In addition to improving the appearance of the dark circles. secondary gain in the form of diminished wrinkles. Photographs demonstrate diminished vascularity of chin and nasal sill.30 milliseconds. and follow-up will generally be limited to the patient’s next treatment visit. with the lesser-pigmented areas showing the most remarkable initial improvement.) tive pain control medication is unnecessary. 2.) . Infraorbital hyperpigmentation. Pretreatment (A) and post-treatment (B) following two treatments with Nd:YAG laser (13 J/cm2. Subsequent treatments at 2. 2): using the Altus Coolglide Nd:YAG laser (Brisbane. the author is able to deliver more energy to the dermis and improve results. the infraorbital region continues to demonstrate normalization of pigmentation. the better the initial results.D. as with nonablative facial rejuvenation. 5-mm spot size.

oriented parallel to resting skin tension lines. The use of a pulse dye laser. some investigators have reported that demonstrable clinical improvement is elusive. and Nd:YAG (1064 nm) lasers are included in this group.234 D. and 650 pulses). The hair follicles are located throughout the skin’s surface. especially in the head and neck region. Reduction of erythema as well as itching and sensitivity can be seen. Scar reduction. in addition to intralesional steroids. alexandrite (755 nm). leg. Minimizing scar formation and appearance is critical to achieving optimal surgical results in elective cosmetic surgery. Excessive hair growth. however. IPL light sources (515 – 695 nm) also will treat unwanted hair growth. Fig. nonablative lasers to stimulate collagen remodeling in hypotrophic scars will help fill in the defect (Fig. Boyden / Oral Maxillofacial Surg Clin N Am 16 (2004) 231–237 Although much attention has been drawn to the positive effects of nonablative facial rejuvenation. typically will undergo three to five treatments for a given site. Hair follicles are larger than melanosomes or melanocytes and are better treated with longer pulse durations— milliseconds rather than nanoseconds. Pretreatment (A) and post-treatment (B) following 3 monthly treatments with Nd:YAG laser (13 J/cm2. This procedure generally is thought to be consistent with Food and Drug Administration guidelines. For scars that are hypertrophic in nature. The preplanned placement of incisions within skin folds or creases. particularly within the female facial region. Although many patients are women seeking treatment for unwanted facial. Hair comprises fibers made of keratin. or bikini-line hair. 3) [7].) . Currently.K. except for the soles of the feet and the palms of the hands. Use of the previously mentioned. lasers capable of a wavelength in the range of 585 nm are beneficial [7].30 milliseconds. particularly from the back and shoulder regions (Fig. underarm. Understanding the growth cycle of human hair is vital to treating excessive hair growth. diode (810 nm). The target chromophore for hair removal is melanin. Hair reduction Perhaps one of the most common cosmetic uses of lasers today is for reduction or removal of unwanted hair. which require devices for hair removal to demonstrate a 30% reduction of hair growth at 3 months following a single treatment. The number of follicles Scar treatment The process of postoperative or post-traumatic wound healing is well known. may not be aesthetically pleasing. The original concept of laser hair removal has undergone changes as the science has evolved. Most patients. Even keloidal scarring may be improved with noninvasive laser treatment. Postoperative wound care is also known to optimize the outcome. 3. the preferred term to describe this procedure is laser hair reduction. 5-mm spot size. 4). is a time-honored method of minimizing surgical scar appearance. Leffell [6] reviewed 11 studies based on human clinical trials designed to test the efficacy of nonabalative therapy in reducing wrinkles due to photodamage and found that the studies failed to present consistent data on the efficacy of nonabalative photorejuvenation to improve or eliminate rhytids. may help minimize the response of fibroblasts [7]. Treatment of scarring is dependent on the type of scar present. The long-pulsed ruby (694 nm). 0. (Photograph property of Olympic Surgical Associates. increasingly more men also are desirous of hair removal.

) that an individual has is determined during fetal development. Terminal hairs are long. Currently. Hair removal. The use of lasers for hair removal is not new technology. The preservation of the epidermis is the critical aspect of patient care when performing laser hair removal. and Xeo. multiple temporally spaced treatments may be needed for successful results. The two major types of excessive hair growth are hypertrichosis and hirsutism. chemical depilatories. The threshold fluence required to damage the follicles is 40 to 70 J/cm2. The active phase of hair growth. Cataphase is a regression phase. California). eyebrows. During this stage. Hypertrichosis is excessive hair growth that is not androgenic in nature. anagen. The duration of cataphase is approximately 3 weeks. 10-mm spot size. shorter. or waxing. no new follicles are produced. electrolysis. women traditionally have used tweezing or plucking.K. Vascular lesions The use of various lasers for the treatment of vascular lesions is well known. thick. and genitals. Because laser hair removal only works efficiently during the telogen phase. The literature is replete with studies using Nd:YAG. shaving. The target site for follicle destruction is an exogenous chromophore (pigment introduced into the hairshaft) or an endogenous chromophore (melanin within the hairshaft).20 milliseconds). These hairs are found on the scalp. the author has found that most hair reduction patients are perimenopausal women. and nonpigmented. face. Coherent Light Sheer (Santa Clara. and pigmented. Longer pulses ( >100 microseconds) seem to cause long-term hair removal [8]. The hair growth cycle may be divided into three distinct phases: anagen. chest. cell division stops. Telogen represents the final phase of the growth cycle. The thermal relaxation time for terminal hair follicles is estimated to be 10 to 100 milliseconds. During telogen. depending on size. California). Women so afflicted find that the fine vellus hairs become coarse terminal hairs. 4. Although the underlying causes of both hirsutism and hypertrichosis may range from endocrine disorders to tumors to common medications. California). catagen. and after parturition. It may occur in both men and women and may be found localized or generalized on the body. back. and infection.D. When treating excessive hair growth. and 0. Pretreatment (A) and post-treatment (B) of hirsutism following a single session with Nd:YAG laser (57 J/cm2. potassium . Altus Coolglide (Brisbane. Changes in androgen production such as those associated with menopause may promote male hair growth patterns including facial hair. The use of these methods produces only temporary hair removal and can result in many possible complications and sequelae including scarring. This stage lasts 2 to 3 months. and telogen. Photoderm (Santa Clara. Palomar Epilaser (Burlington. Electrolysis is particularly uncomfortable to undergo. The fine hairs found on the forehead are examples of vellus hairs. the hair falls out and the follicle begins preparation for the development of new hair. may range from 1 to 2 months on the arm to 5 to 7 years in the scalp. diode. Hirsutism is an increased hair growth in unusual places. The first device for laser hair removal was marketed in 1996 [8]. There are two major types of hair: terminal and vellus. Massachusetts). Vellus hair is thinner. there are a number of lasers approved for hair removal including Lumens Epilight (Santa Clara. folliculitis. Boyden / Oral Maxillofacial Surg Clin N Am 16 (2004) 231–237 235 Fig. (Photograph property of Olympic Surgical Associates. California).

in which a refrigerant medium is delivered to the target area immediately before the laser pulse [10]. Melanocytes were destroyed. venules. Therefore. The pulse duration must be long enough to allow conduction of heat from the vessel lumen to the vessel wall. A lesion may be considered unaesthetic due to any number of specific considerations including size. port-wine stains or large hemangiomas). and IPL. flow rate variability. In some cases (eg. Use of the long-pulse Nd:YAG laser (1064 nm) also is gaining popularity. cafe macules. greater success is seen [8]. An excess of melanin contained within melanosomes will cause hyperpigmentation. Telangiectasias (‘‘spider veins’’) comprise 90% of the vascular lesions treated in the author’s practice. pulsed dye. Epidermal hyperpigmentation is due to an increased rate of melanogenisis or an increased number of melanocytes. Laser treatments provide an excellent ´ au lait option to treat localized dyschromias. Lasers that emit energy absorbed by hemoglobin and oxyhemoglobin (approximately 570 – 590 nm) will be best suited for treatment of vascular lesions. nevus of Ota. The nose. depth. keratinocyte. and other pigmented lesions. bright-red lesions. color. and IPL technology.’’ The goal of treating vascular lesions is the eradication of the lesion. purpura. Telangectasias most commonly are seen in patients with Fitzpatrick I or II skin types [9]. Differentiating between epidermal and dermal lesions is important in achieving an optimal treatment outcome. equipment manufacturers have developed methods for cooling the epidermis. The target chromophore for vascular lesions is hemoglobin or red blood cells. Dermal hyperpigmentation is due to excess melanin deposits in the dermis [11]. potassium titanyl phosphate. lentigines. or number. Boyden / Oral Maxillofacial Surg Clin N Am 16 (2004) 231–237 titanyl phosphate. krypton. all of these sites are near bony foramina of the skull transmitting named vessels. will encounter mainly facial telangectasias. whereas venules are blue and may protrude above the skin’s surface. hemangiomas. Telangiectasias can be grouped into four categories: arborized. An indirect target is the vessel wall. because the smallest IPL quartz filter measures 12 Â 8 mm. and differences in target chromophores. Disruption of the melanosome leads to the death of the cell containing it. Lasers with cooling devices come in two varieties: (1) contact cooling. simple.236 D. however. and spider [9]. whereby the laser tip maintains contact with the skin. The absorption spectrum of hemoglobin and oxyhemoglobin has several peaks. or dyspigmentation. or pulsed dye lasers. however. or melanophage [12].K. The spectrum of absorption for melanin is broad: 250 to 1200 nm. or rosacea. better penetration to the hemaglobin target. Capillary lesions are smallest in diameter and red. Longer wavelengths allow for deeper tissue penetration because melanin absorption decreases as the wavelength increases. the selection of the appropriate chromophore is the first step in achieving optimal cosmetic outcomes. but the outcomes were variable. papular. These vessels are found most often to be less than 1 mm in diameter. and chin are the most common sites for patients presenting for treatment. Coagulation of the endothelial layer alone is not sufficient for resolution. Benign pigmented lesions The cosmetic impact of pigmented lesions in the maxillofacial region can be significant. location. even without complete resolution. Initial laser use for human skin in the early 1960s used a ruby laser with a wavelength of 694 nm. All vessels—from lower leg varicosities to peripheral angiomas—can be treated with laser technology. They may become larger and change to blue or purple as venous backflow increases hydrostatic pressure [9]. or (2) spray cooling. To prevent these undesirable side effects of vascular laser therapy. or capillaries. there are numerous laser options to treat these lesions. This laser takes advantage of a smaller peak of absorption in hemoglobin near this wavelength. Using the 3-mm spot size of the Altus Coolglide laser. They represent dilated arterioles. the surrounding normal tissue must be covered to avoid damage. simply diminishing the size or severity of the lesion may provide an acceptable cosmetic outcome. especially with the IPL devices. The argon laser (488 – 514 nm) was used in . As the depth of mural damage progresses from the endothelial layer through the intima and the media to the adventitia. however. cheeks (malar eminence). therefore. The maxillofacial surgeon who primarily treats lesions of the head and neck. Gel is commonly used. whether it is a melanocyte. Because of vessel diameter. no single option has been established as a ‘‘gold standard. As with all laser procedures. The Photoderm IPL will also remove facial telangiesctasias. Cutting a slit or hole in a self-adhesive label or sheet of paper or cardboard is effective in isolating specific sites and minimizing adjacent erythema. This group of lasers includes argon. Arteriolar vessels are flat. This peak also coincides with diminished absorption by the melanin chromophore and. cutaneous vessels can be removed quickly and comfortably. port-wine stains. Interestingly.

Epidermal lesions may be treated in numerous ways. 2nd edition. Laser treatment of cutaneous vascular lesions. Their inclusion is not an endorsement of any individual type of laser or manufacturer. studies. is beyond this review. knowledgeably. keratoses. Currently. Dermatol Clin 2002. editors. Alt TH. with clearing in 5 to 10 days. [12] Klimer SL. In: Arndt KA. The use of lasers that emit 488.to 532-nm wavelengths is commonplace. p. Boyden / Oral Maxillofacial Surg Clin N Am 16 (2004) 231–237 237 an attempt to achieve better results. Dermatol Surg 2000. It is wise to test any equipment in the clinic for as long as possible before purchase. Laser eradication of pigmented lesions and tattoos. cafe and ephelides are treated effectively with laser technology. Plastic Surgery Products 2003. Deeper lesions such as postinflammatory hyperpigmentation. injectable fillers. half-face study comparing topical vitamin C and vehicle for rejuvenation of photodamage. Epidermal lesions ´ au lait macules. p. Full face nonablative dermal remodeling with a 1320 nm Nd:YAG laser. however. injectable fillers. In: Coleman III WP. Selective non-ablative wrinkle reduction by laser. Summary As patients become more aware of their options related to facial enhancement. The reader is encouraged to investigate thoroughly any claims.R. [5] Goldberg D. 2nd edition. [8] Dierickx CC. editors. a complete understanding of the laser’s physics. If the junction of the reticular dermis and the papillary dermis is below the level of tissue injury. Cosmetic surgery of the skin. with each option having its own claims of efficacy. nonsurgical offerings will become an ever larger component of the cosmetic practice. then these wounds generally heal without scarring. Cutaneous lasers. The history of dermatologic cosmetic surgery. state. References [1] Coleman III WP. Hanke CW. J Cut Las Ther 2000. St. editors. Philadelphia: Lippincott-Raven Publishers. These procedures are part of an overall practice philosophy of which skin care and maintenance is a vital component. 19 – 178. 1 – 6. botulinum toxin.K. may be used to treat superficial pigmented lesions of the skin by simple coagulation of the epidermis. Fitzpatrick RE. Rostan EF. Clement M. such as a carbon-dioxide laser. Facial Plast Surg Clin North Am 2001. Using these new technologies effectively. these laser procedures provide a comprehensive menu of services for contemporary maxillofacial surgery practices. and some congenital nevi also can be safely treated with laser therapy. [11] Dover JS. Patients will continue to demand rejuvenating options but will desire a minimum of downtime. p. local. 1999. botulinum toxin. and invasiveness. These technologies are not inexpensive to acquire. 1997. The noninvasive laser and IPL cosmetic procedures covered in this article are only a few of the uses for lasers in cosmetic maxillofacial surgery. and necessary ancillary supplies is manda- . Dover JS. personnel required. Heickendorff L. 26:915 – 8. with their much longer wavelength.11:229 – 43. [6] Leffell DJ. 28:231 – 6. such as lentigos. these results also were variable [11]. The use of traditional skin care approaches such as microdermabrasion. Fitzpatrick RE. melasma. tory. [7] Kilmer SL.9(4):577 – 83. and prescription-grade skin care products will be accentuated by the advances in laser and IPL technology. [9] Goldman MP. [10] Lang PG. superiority. A number of the lasers mentioned in this review are those with which the author has had significant experience. Dermatol Clin 2002. et al. or regional rules and regulations may impact the use of laser technology in any given practice. Dermatol Surg 2002. p.20(1):37 – 53. dozens of lasers exist for noninvasive cosmetic procedures.2:9 – 15. and ease of use. even carbondioxide lasers. Hair removal by lasers and intense pulsed light sources. Cutaneous laser surgery. 24.138: 11503 – 8. discomfort. and so forth. Lasers for the treatment of cutaneous pigmented disorders. [3] Fitzpatrick RE. ISSN Number 1084 – 1660. Clinical efficacy of devices for nonablative photorejuvenation. Olbricht SM. Facial Plast Surg Clin N Am 2003. In conjunction with prescription skin care products. 1997.20:135 – 46. [2] Noodleman F. Understanding how skin ages. and safely is crucial for the maxillofacial surgeon to maintain the leading role in facial cosmetic surgery. et al. Lesions confined to the epidermis can be removed by any method that removes the epithelium. Louis (MO): Mosby. Initial darkening of the lesion is often seen. Saint Louis (MO): Mosby-Year Book. microdermabrasion. Lasers in cutaneous and aesthetic surgery. In: Goldman MP. 165 – 87. Hanke CW. This wide range of options. In fact. In addition. or promises made by any manufacturer. Kane KS. Multiple treatments are sometimes required to achieve resolution. Double blind. Laser technology: its application in the management of hemangiomas and vascular malformations for the head and neck. [4] Bjerring P. Arch Dermatol 2002.D.