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Received: 17 February 2019    Revised: 26 May 2019    Accepted: 28 May 2019

DOI: 10.1111/jocd.13050

ORIGINAL CONTRIBUTION

Laser Skin Rejuvenation With Fractional 1064 Q‐switched

Nd:YAG In 252 Patients: An Indian Experience

Madhuri Agarwal MBBS, MD, DDV1  | Sangeeta Velaskar MBBS, MD, DVD2

1
Yavana Aesthetics Clinic®, Mumbai, India
2 Abstract
Medical and R&D, Kaya Limited, Mumbai,
India
Correspondence
Madhuri Agarwal, Yavana Aesthetics Clinic®,
236‐239, Hallmark, LBS Marg, Mulund West,
Mumbai‐400080, India.
Email: drmadhuri@yavana.in
Objective: The objective of our study was to present the results and safety profile
of fractional 1064 Q‐switched Nd: YAG laser treatment in skin rejuvenation in Indian
patients with Fitzpatrick skin type III‐VI.
Materials and methods: We studied our clinical data of 252 patients who underwent
treatment for facial skin rejuvenation with the Q switched Nd:YAG laser 1064 wave‐
length, using the fractional mode of 5mm spot size with fluences from 1.2 J ~ 2 J/cm2
and the energy ranging from 300‐500 mJ, a repetition rate of 7Hz and pulse duration
of 8 ns for 6 sessions at two weekly intervals. We evaluated results with the aid of
clinical photography taken before start of treatment, on 3rd and 5th sessions along
with patient satisfaction and dermatologist assessment scores. Any adverse events
were also recorded.
Results: At the end of 6 sessions, both patients and dermatologists reported visible
improvement in skin texture and tone. The laser sessions resulted in an immediate
improvement in skin texture and tone in the first session itself that increased over
3 sessions and then stabilized. Transient erythema was reported in a few cases. No
hypo‐ or hyperpigmentation were noted.
Conclusions: The 1064 QSNYL is popularly used for skin rejuvenation especially in
the Asian countries. But there is lack of substantial clinical data to validate the clini‐
cal results. We present the first study that shows the fractional 1064 Qswitched
ND:YAG laser is a safe and effective option for skin rejuvenation in skin types III‐VI.

KEYWORDS
1064 Q‐switched ND:YAG laser, fractional mode, skin rejuvenation, skin type III‐VI

1 |  BAC KG RO U N D
A wish for a smoother, even, flawless, youthful looking skin has al‐
ways been a priority for both men and women across continents.
Factors including heredity, sunlight, pollutants, smoking and alcohol
1
intake, and aging itself contribute to patchy, dry rough skin leading
to dull, uneven skin tone and unattractive skin. Skin rejuvenation is a
treatment modality designed to improve aesthetic concerns caused
by many of above‐mentioned factors.
Photoaging is a common and principal cause of dull, dark skin,
commonly affecting face, décolleté area, arms, back of hands, and
sides of neck. Due to the involvement of exposed areas, photoa‐
ging has a profound psychological impact on affected individuals. 2
Photorejuvenation is defined as the treatment of damage caused
due to sun‐induced and other environmental factors utilizing light
or visible or infrared light energy sources.3-5 Visible disturbance to
overlying epidermis should be avoided while trying to achieve this
in a nonablative manner. The treatment consists of the recontouring

J Cosmet Dermatol. 2019;00:1–6. © 2019 Wiley Periodicals, Inc. |  1

wileyonlinelibrary.com/journal/jocd  
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2       AGARWAL and VELASKAR
TA B L E 1   Skin type demographics
Skin type Patients Male Female
III 11 0 11 (100%)
IV 112 20 (18%) 92 (82%)
V 62 26 (42%) 36 (58%)
VI 67 10 (15%) 57 (85%)
Total 252 56 (22%) 196 (78%)
of mild surface irregularities through subsequent dermal collagen
remodeling.3-5
The Q‐switched Nd:YAG lasers are commonly used for the
management of hyperpigmented lesions such as nevus of Ota, tat‐
toos, melasma.6 However recently, it has been found useful in skin
rejuvenation.
The rejuvenation effect of Q‐switched lasers occurs due to
dermal collagen remodeling caused by dermal thermal injury with‐
out causing epidermal damage. The Nd: YAG laser wavelength of
1064 nm is associated with increased collagen deposition in the pap‐
illary and upper reticular dermis,6-10 and it has also been suggested
that this wavelength may lead to a deeper dermal wound that can
be utilized for nonablative dermal remodeling7. In addition, heat‐in‐
duced protein (hsp) 70 and procollagen 1 have been reported to be
expressed in dermal dendritic cells and it is suggested that these
cells may participate in dermal collagen deposition after the treat‐
ment. 8 The fractional 1064 Q‐switched Nd:YAG (QSNYL) laser has
become quite popular for facial rejuvenation in South‐East Asia as
it provides visible efficacy and overcomes most of the undesirable
effects of traditional available lasers specially in a darker skin type.
Herein, we present our experience of using the fractional 1064
QSNYL laser for facial rejuvenation in Indian skin—a first of its kind
for facial rejuvenation in darker skin types in a large population of
252 Indian patients.
2 |  M E TH O D O LO G Y
It was a retrospective study, wherein patient records of 252 cases,
both adult males and females with skin types III – VI who underwent
facial rejuvenation with fractional 1064‐nm Q‐switched Nd:YAG
TM
laser (Helios II , Laseroptek, Korea) and completed 6 sessions,
were analyzed. The patients who had concern of patchy skin, discol‐
oration, uneven skin tone, and dullness, and wanted facial skin reju‐
venation were included in the study. Patients with systemic disease
or other facial skin disorders, active acne lesions or infections, apply‐
ing any type of topical medications on face, use of oral isotretinoin
past 6‐8 months, and pregnant and lactating patients were excluded.
We followed our standard operating protocols for the treatment
in our practice. Detailed physical examination of skin was carried
out. A written consent was obtained from all patients after explain‐
ing about the risks, benefits, and potential complications of the laser
therapy.
Each patient underwent 6 treatments at two weekly intervals,
using 1064 fractional mode at 5  mm spot size, 10‐Hz repetition
rate, fluence ranging from 1.2 J to 2 J/cm2 , and the energy rang‐
ing from 300 to 500 mJ in all sessions. The percentage of skin
coverage using fractionated handpiece was around 10.6% (spot
diameter@ 500mJ is around 0.2 mm). The skin was covered with
an overlap of 50% of the laser between 2 laser shots. In each treat‐
ment, 2 passes were done with laser on face and neck. Patients
had been advised to avoid direct sunlight and liberal use of sun‐
screen postprocedure.
Clinical photographs were taken before treatment and post‐
treatment at third and fifth sessions. The patient and the treating
dermatologist determined clinical improvement in every session.
The clinical improvement criteria were mapped as scores both by
patient and by dermatologist. The patient scored the improvement
on the basis of color, texture, radiance, and even tone of skin. The
dermatologist scored the improvement on smoothness, skin texture,
even tone, pore tightening, and pigment reduction. The scoring scale
utilized by both the patient and the treating dermatologist was as
follows:
1. Poor (0%‐25% improvement)
2. Average (25%‐50% improvement)
3. Good (50%‐75% improvement)
4. Excellent (>75% improvement).
Patient comfort and adverse effects if any were also recorded at every
session by the dermatologist.
3 | R E S U LT S
The data were analyzed only from patients on completing the rec‐
ommended 6 sessions of 1064 QSNYL. Among 252 adult patients,
22% were males and 78% were females with majority presenting
in the age group of 30‐40 years. Most patients were between skin
types V and VI (52%), 44% patients were skin type IV, and the rest
4% were skin type III (Table 1). There were no dropouts in the study,
and all patients completed the prescribed 6 sessions.
The patients and dermatologist noted marked improvements in
clinical appearance starting from first session onward. The results
seen were in the form of lightening, brightening, tightening of skin,
and bleaching of the facial hair, leading to an even smooth texture
and tone, thereby achieving a complete laser toning. The treatment
was well tolerated by even the sensitive skins. There was no down‐
time noted at the end of each session that was of an added advan‐
tage to the subjects.
29% patients rated treatment as excellent, 55% as good, and re‐
maining 16% as average (Figure 1). The treating dermatologist rated
25% patients as excellent, 64% patients as good, and 11% as aver‐
age (Figure 2). Thus, most patients showed excellent improvement
in skin tone, texture, and pigmentation after 3 sessions of QSNYL
laser (Figure 3A‐F). No patient or dermatologist rated results as poor.
AGARWAL and VELASKAR
F I G U R E 1   Patient Satisfaction score
F I G U R E 2   Dermatologist assessment score
There were no significant adverse effects noted in any patients
except transient mild erythema in a few was reported which settled
immediately after treatment.
4 | D I S CU S S I O N
Prolonged sun exposure causes significant skin changes that are
clinically manifested as mottled pigmentation and other dyschromia,
erythema, telangiectasia, wrinkles, textural changes, and enlarge‐
ment of pores. Solar elastotic collagen damage produces a sallow
skin tone, dilated pore structure, and an appearance and elasticity
similar to crepe paper.7 Due to the concern of aging and the need of
maintaining a fresh, youthful looking skin with negligible downtime,
facial rejuvenation using nonablative techniques is gaining popular‐
ity in recent times.
Ablative skin resurfacing with high‐energy, short‐pulsed or
scanned CO2 lasers has been used for aesthetic skin rejuvenation.
Excellent clinical results have been seen when these lasers are
used to treat facial rhytids. However, reepithelialization following
|
      3
(A) (B)
(C) (D)
(E) (F)
F I G U R E 3   Most patients showed excellent improvement in
skin tone, texture, and pigmentation after 3 sessions of QSNYL
laser. (A) Patient 1 pretreatment, (B) patient 1 post–third treatment,
(C) patient 2 pretreatment, (D) patient 2 post–third treatment, (E)
patient 3 pretreatment, (F) patient 3 post–third treatment
treatment with these lasers takes 7  ±  14  days and the laser‐cre‐
ated wound is accompanied by intense erythema, discharge, and a
burning sensation during the postoperative period. The erythema,
sometimes lasting for months, often requires extensive camouflage
makeup. This amount of downtime and posttreatment discomfort
is not acceptable in many patients, especially among Indians where
aging manifests more as pigment and texture alterations rather than
frank wrinkles and lines.
Various new approaches to laser resurfacing have recently
been evaluated. Recently, the Er:YAG has been shown to improve
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4       AGARWAL and VELASKAR
photoaged skin with the potential for quicker healing and decreased
11-13
erythema. However, epidermal ablation is still required.
1064 QSNYL is one of the latest modalities used for nonablative
facial rejuvenation. It offers the benefit of being a true lunchtime
procedure, quick, easy, painless, needing no topical anesthesia, and
allowing the patient to resume normal routine immediately. Even
though this modality has become widely accepted in Asian coun‐
tries, there is a paucity of published data discussing the rejuvenation
effect of QSNYL in literature.
Goldberg et al conducted a comparative study with QSNYL
and char‐free CO2 laser. The study indicated that QS Nd:YAG laser
may be efficacious in treatment of periorbital and perioral rhytids.
11 patients treated with the char‐free carbon dioxide lasers were
improved, and 9 of 11 patients treated with QS Nd:YAG laser were
improved. Healing (complete reepithelialization) was noted to occur
3‐6  days earlier in sites treated with the QS Nd:YAG than in sites
treated with char‐free carbon dioxide lasers. Pigmentary changes
14
were not observed in any treatment site.
Lee at al. conducted skin rejuvenation using 1064 nm QS Nd:YAG
in Asian patients. The subjective and objective evaluation by sub‐
jects and two independent physicians demonstrated significant im‐
provement in all assessments of skin texture, skin tone, pore size,
and sebum secretion (P<0.001). In an objective evaluation of the
F I G U R E 4   Comparison between conventional low fluence Q‐switched laser vs. fractional 1064 QS Nd:YAG
data recorded by VISIA, significant improvement was noted in skin
texture, pore size, visible spots, and uneven pigmentation visible
with UV reflectance photography (P<0.05).15
In another study by Lee MW, 50 patients were treated with the
Nd:YAG laser alone. They showed improvement of 10% to 30% in
skin tone/tightening, 20% to 30% in skin texture, 10% to 30% in
rhytids, and 60% to 80% in patient satisfaction.10
The purpose of our study was to retrospectively examine the use
of a fractional 1064 Q‐switched Nd:YAG laser for skin rejuvenation.
We wanted to choose an efficacious treatment which is nonabla‐
tive, thereby providing low rate of adverse effects and minimal to
no downtime. Here, patients and dermatologists reported excellent
results in initial three sessions in terms of drastic improvement in
skin color, texture, tone, and radiance from the baseline. From the
fourth session onwards, these results were minimally incremental as
reported by the patients. Since the results post–fourth session were
not dramatically appreciable as compared to initial first 3 session's
results, on completion of 6 sessions, most patients expressed the
result scores were good to average.
However, treating dermatologist observed an overall marked im‐
provement in skin texture, tone, pigment reduction, and pore tight‐
ening on the completion of 6 sessions; hence, they reported a higher
percentage of good scores. There was a good concordance between
AGARWAL and VELASKAR
the patient and the physician, in rating of results, with respect to skin
color and texture improvement.
The incidence of postinflammatory hyperpigmentation following
1064‐nm Q‐switched Nd:YAG laser treatment is common in Asians
ranging from 18% to 73% of the treated cases in various studies.16
Polnikorn et al reported postinflammatory hyperpigmentation in
39.4% of the patients undergoing 1064‐nm QSNYL laser treatments
over 3 months.17 In a study by Chen et al combining vitamin C sono‐
phoresis and Nd:YAG laser in Asian patients, severe postinflamma‐
tory hyperpigmentation was seen in 21.8% of the patients.18 Other
potential complications of laser toning in especially in a darker skin
type include physical urticaria, acneiform eruption, minute pete‐
chiae, whitening of fine facial hair, herpes simplex reactivation, leu‐
koderma, and mottled hypopigmentation.19 Kim et al showed three
melasma Asian patients who developed punctate leukoderma after
laser toning with 1064 nm QSNYL at 2‐weekly intervals. 20 In a study
by Wattankarai, mottled hypopigmentation was seen in 3 out of 22
melasma patients after five sessions of weekly laser toning. 21 The
incidence of hypopigmentation was 8.3% in a study by Vachiramon
et al22 Mottled or punctate hypopigmentation can be due to too
high fluence causing direct phototoxicity and cellular destruction of
melanocyte. Other possible mechanisms for the hypopigmentation
are intrinsic unevenness of skin pigmentation and nonuniform laser
energy output. 22 None of our 252 patients saw any major adverse
effects. This can be due to the fact that in our study, we have used
the fractional mode of QSNYL instead of the conventional large spot
size mode of QSNYL.
The purpose of fractional handpiece in our study was to reach
the deep penetration depth (for deep dermal pigmentation) and
to avoid the thermal damage (burn), leading to the adverse effects
of hyperpigmentation or mottling and hypopigmentation. Figure 4
clearly demonstrates the difference between conventional QSNYL
and fractional QSNYL.
It is well established that fractional lasers were developed for the
purpose of skin rejuvenation, and when used to treat photodamage,
pigment lightening occurs over a series of successive treatments by
means of pixilated destruction of columns of epidermal and dermal
tissue, which are subsequently eliminated from the skin surface. 23-25
This drastically reduces the incidence of adverse effects.
A limitation of our study is that it is retrospective in nature and
also it lacked an objective scoring system. Due to the retrospective
nature of the study in clinical practice, usually we are unable to use
an objective scoring system or do a comparative study. We were also
unable to conduct a biopsy of the treated face after the laser therapy
due to ethical reasons so the actual histopathological findings after
the laser treatment are not clear. Another limitation was the inability
to follow up with the patients after completion of treatments for
assessing the longevity of results. Further, controlled, comparative
studies on the detailed objective evaluation, real‐time histopatho‐
logical findings, and time duration of efficacy postcompletion of
treatment will complement our study. Long‐term studies to assess
the ability to sustain the neocollagenesis and remodeling effects of
laser toning are required.
|
      5
5 | CO N C LU S I O N
This is the first study of fractional 1064 QSNYL done in a large group
of 252 patients with skin types III‐VI. The treatment done with frac‐
tional mode of 1064 QSNYL is a safe and effective modality of re‐
juvenation in Asian skin types with results visibly appreciable in 2‐3
sessions and no downtime.
AC K N OW L E D G M E N T
The authors thank Dr Sendhil Kumaran for his support and guidance.
ORCID
Madhuri Agarwal  https://orcid.org/0000-0002-8122-0368
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How to cite this article: Agarwal M, Velaskar S. Laser Skin
Rejuvenation With Fractional 1064 Q‐switched Nd:YAG In
252 Patients: An Indian Experience. J Cosmet Dermatol.
2019;00:1–6. https​://doi.org/10.1111/jocd.13050​