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Received: 19 December 2020    Revised: 11 January 2021    Accepted: 18 January 2021

DOI: 10.1111/jocd.13958

ORIGINAL CONTRIBUTION

1540-­nm fractional erbium: Glass laser is a safe and effective

modality for nonablative facial rejuvenation

Efrat Solomon-­Cohen MD, MOccH1,2  | Moshe Lapidoth MD, MPH1,2 |

Daniel Mimouni MD1,2 | Lehavit Akerman MD1 | Dan Slodownik MD1,3 |
Emmilia Hodak MD1,2 | Assi Levi MD1,2

1
Sackler Faculty of Medicine, Tel Aviv
University, Tel Aviv, Israel
2
Laser Unit, Division of Dermatology, Rabin
Medical Center, Petah-­T iqva, Israel
3
Department of Dermatology, Tel Aviv
Souraski Medical Center, Tel Aviv, Israel
Correspondence
Efrat Solomon-­Cohen, Laser Unit, Division
of Dermatology, Rabin Medical Center,
Petah-­T iqva, Israel.
Email: efratsolomon@gmail.com
Abstract
Background: Laser treatments for facial rejuvenation are common, with ablative mo-
dalities being of more common use for this indication. Efficient nonablative modali-
ties are of rising demand.
Aim: Our aim was to determine the safety and efficacy of high-­fluence, nonablative
1540-­nm fractional Erbium:glass laser for facial rejuvenation.
Patients and Methods: A retrospective study of patients treated with 3-­4 treatments
using the 1540-­nm fractional Erbium:glass laser for facial rejuvenation, using 2500-­
3000 mJ/stacked pulses (51-­61 mJ per pixel). Patients were followed-­up for 3 months
following their last treatment. Before and after photos were independently blindly
evaluated by 2 dermatologists, who graded them using a scale from 0 (exacerbation)
to 4 (76%-­100% improvement) for 2 different facial regions (frontal face region and
lateral canthal region). Pain perception and adverse effects as well as patient satisfac-
tion were documented throughout the study.
Results: Sixteen patients completed both treatment and follow-­up period. At the
3-­
months posttreatment follow-­
up visit, moderate-­
to-­
significant improvement in
rhytids appearance (mean grade of improvement: 2.93 for frontal face and 3 for lat-
eral canthal region) was observed. Patients’ satisfaction was high (4.25). Patients re-
ported mild and transient erythema posttreatment with no other adverse effects.
Conclusion: The high-­fluence 1540-­nm fractional Erbium:glass laser is a safe and ef-
fective nonablative modality for facial rejuvenation.

KEYWORDS

Erbium:glass laser, facial rejuvenation, nonablative laser, rhytids, wrinkles

1 |  I NTRO D U C TI O N
Skin aging, a natural dermatological process occurring as people ad-
vance with age, is a common cause for aesthetic discomfort, often
resulting in lower self-­esteem and/or a significant nuisance to daily
living.1 Therefore, patients often seek effective therapeutic modali-
ties that can assist in slowing or minimizing this natural deterioration
in skin laxity and texture.1,2 The pursuit for a safe and effective
modality, with minimal downtime and limited adverse effects, con-
stantly continues, involving physicians, scientists, and patients
alltogether.1,2
Current therapeutic modalities for the treatment of facial skin
aging include: a surgical facelift, tissue augmentation with inject-
able fillers, botulinum toxin injections, chemical peels, energy-­based

J Cosmet Dermatol. 2021;00:1–5. wileyonlinelibrary.com/journal/jocd© 2021 Wiley Periodicals LLC     1 |

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2       SOLOMON-­COHEN et al
devices, topical applications, and others.1–­6 Energy-­based devices
such as: intense pulsed light (IPL), radiofrequency, and lasers are
of growing use for this purpose in recent years.7–­9 The ablative la-
sers (the 10 600-­nm CO2 laser and the 2940-­nm Erbium:YAG laser)
are of more common use; however, they are associated with sig-
nificant adverse effects (dyspigmentation, edema, and erythema),
risk for infections, and significant postprocedure downtime.10–­17
Nonablative lasers with a much shorter postprocedure downtime
have heterogeneous efficacy in the treatment of facial rhytids and
10–­17
skin rejuvenation.
Laser fractionation, applied both for ablative and nonablative
lasers, refers to the formation of microscopic treatment zones ad-
jacent to spared intact skin: a laser beam is manipulated via diffrac-
tive lens, in which multiple microscopic laser beams are delivered
into microscopic treatment zones, sparing the intervening areas.17–­21
This allows minimal epidermal damage, resulting in fewer adverse
effects, as well as a shorter overall postprocedure downtime.17–­21
While ablative fractional lasers have shorter downtime and a better
safety profile than the "classic" nonfractional ablative lasers, they
still have considerable adverse effects, such as: erythema, edema,
risk for infections, and scarring.10–­16,24 Fractional treatments with
the 1540-­nm Erbium:glass laser have previously shown to induce
collagen production and stimulate dermal remodeling, explaining its
positive effect in treating facial acne scars, skin rejuvenation, striae
distensae, and more.17–­24 In this study, we used a new 1540-­nm
nonablative fractional Erbium:glass laser probe (ClearSkin Pro, Alma
Lasers LTD), which is capable of delivering high fluencies of up to
61 mJ per pixel.
1.1 | Aim
The aim of our study was to determine the safety and efficacy of a
new high-­fluence 1540-­nm nonablative fractional Erbium:glass laser
for facial rejuvenation.
2 |  PATI E NT S A N D M E TH O DS
2.1 | Patients
This is a retrospective cohort study. We included female patients
above the age of 35 years who had been previously treated in our
clinic due to mild to moderate facial rhytids. We excluded patients
as following: (a) previously undergone a surgical facelift; (b) previ-
ously treated with ablative laser up to one year prior to treatment; (c)
previously treated with any laser device up to three months prior to
treatment; and (d) applied any topical treatment up to 14 days prior
to treatment.
Standardized high-­resolution digital photography of the treat-
ment area was performed for routine follow-­up purposes, for each
patient at baseline, before each treatment, and at the 3-­month fol-
low-­up visit. These photos were later used for outcome evaluation.
The Visual Analog Scale (VAS) was used to quantify rhytids se-
verity (grade 0 = excellent appearance, grade 5 = poor appearance)
during the screening visit.
2.2 | Treatment
Patients were treated with a 1540-­nm fractional Erbium:glass laser
(ClearSkin Pro, Alma Lasers LTD), every 4-­6  weeks. The required
number of treatment sessions was determined according to clinical
improvement.
Treatment area was disinfected prior to each treatment.
Protective eyewear was utilized during treatments. Laser settings
included spot size of 11*11 mm with a fractionation of 49 pixels,
fluence of 2500-­3000 mJ/pulse (51-­61 mJ per pixel), and 2 stacked
pulses were emitted at a rate of 1Hz for 2-­4 passes per treatment
session (2500 mJ/pulse was used for the initial treatment, with in-
crease to 3000 mJ/pulse if no adverse effects were noted). Overall a
single treatment session required approximately 20-­25 minutes per
session for treatment of the entire face.
All settings were preadjusted according to the patient's tolera-
bility and comfort.
2.3 | Outcome measures
A blinded clinical evaluation for overall facial appearance was per-
formed by 2 dermatologists using the high-­resolution digital pho-
tos. Two facial regions were separately evaluated: (a) frontal face
region and (b) lateral canthal region ("crow's feet" area).Outcome
was graded as following: 0 (exacerbation), 1 (1%-­25% improvement),
2 (26%-­50% improvement), 3 (51%-­75% improvement), and 4 (76%-­
100% improvement).
A blinded "before/after" analysis was additionally performed by
both evaluators.
Pain perception was assessed by the patient using a 0 to 10 VAS
grading scale (0  = none, 10 =  severe). Adverse effects were esti-
mated by the treating physician, including: erythema, edema, dyspig-
mentation, blistering, flaking, dryness, and/or pruritus, using a 0 to 3
grading scale (0 = none, 1 = mild, 2 = moderate, 3 = severe) during
each treatment and follow-­up visit. Any additional adverse effects
were recorded. Patients’ satisfaction was assessed at the 3-­months
posttreatment follow-­up visit, graded on a scale of 1-­5 (1 = not sat-
isfied, 5 = very satisfied).
3 | R E S U LT S
Sixteen female patients were included. Ages ranged from 36 to
55 years (mean 45 ± 4.7). Fitzpatrick skin types were II to III. All pa-
tients were seeking to aesthetically improve their facial appearance.
All patients had mild to moderate facial rhytids at baseline. All
16 patients completed both treatment and follow-­up period (3-­4
SOLOMON-­COHEN et al
sessions, mean 3.2 ± 0.4). The blinded "before/after" analysis yielded
a correct identification of 84% in the frontal face region and 87.5% in
the lateral canthal region.
Improvement in overall facial appearance occurred gradually
over the course of treatment sessions. Following completion of
treatment, all but one patient (patient number 7) demonstrated a
moderate improvement as assessed by the quartile scale: mean of
2.93 points of improvement in overall frontal face region appearance
(SD  =  0.75), and mean of 3 points in overall lateral canthal region
appearance (SD  =  0.74). Inter-­observer agreement for overall im-
provement was 83% for both views. Figures 1 and 2 portray repre-
sentative cases. Patients’ self-­rated satisfaction ranged from 2 to 5
(mean 4.25 ± 1.06) at the 3-­month follow-­up visit. One patient had
rated her satisfaction level at 2 (6%); whereas, 10/16 patients (63%)
had rated their satisfaction level as 5. The other 5 patients' self-­rate
satisfaction score was 3-­4 (31%). All adverse effects were mild and
well-­tolerated by patients and included mild transient erythema,
mild edema, and mild to moderate pain (mean VAS 3.6  ±  1.7). No
vesicles were noted. No adverse effects were noted at the follow-­up
visits. No downtime was reported following treatment by any of the
patients.
4 | D I S CU S S I O N
Facial rhytids are aesthetically challenging and may cause severe
aesthetic discomfort.1,2 Various treatment modalities are of cur-
rent use for facial rejuvenation purpose, as previously discussed.3–­10
Fractional nonablative lasers are considered safer modalities com-
pared to the ablative ones as they demonstrate a lower pain levels,
better side effect profile and a shorter downtime.10–­16,24
Our results demonstrate an overall moderate improvement
in facial rhytids appearance, a high level of patient satisfaction
3 months following treatment as well as a good safety profile, with
no downtime.
This new nonablative 1540-­
nm fractional Erbium:glass laser
probe can deliver a fluence of up to 3000  mJ/pulse, which results
(A)
(B)
F I G U R E 1   Frontal face region view
of 2 representative patients at baseline
(A, B) and at 3-­months post treatment
(C, D)
|
      3
in significant coagulation and increased efficacy. A relatively short
treatment duration, minimal pain without epidermal injury, and
minimal to no downtime makes this treatment attractive for both
patients and physicians. Much like other nonablative modalities, re-
peated multiple sessions are required with the 1540-­nm fractional
Erbium:glass.10
As previously mentioned, in our study, patient satisfaction
was very high with a mean score of 4.25 out of 5. This presents an
apparent discrepancy between self-­s atisfaction and objective im-
provement, which was assessed by 2 evaluators as moderate (ap-
proximately 50% of improvement). This finding can be attributed
to several factors associated with the subjective convenience of
the treatment—­very few side effects, an overall tolerable pain level,
and most importantly, no postprocedure downtime, which is a key
factor to consider in aesthetic procedures. Another possible expla-
nation for this discrepancy is perhaps the subtle improvement in
skin texture that unfortunately can't be assessed via photographic
2D imaging evaluation alone (however it is taken into consideration
by the patient when grading their own satisfaction level). It is note-
worthy that although the range for patient satisfaction score was
wide (between 2-­5, as mentioned previously), this was due to one
patient that was not satisfied with the posttreatment aesthetic
result. It does not appear that this low score was related to side
effects, as her reported pain level score was low (3 out of 10 on
the VAS scale) and no other side effects were documented. This
being said,63% of patients had rated their satisfaction level as 5
(the highest score), which was noted in the overall high patient sat-
isfaction mean score.
Our study holds several limitations: a relatively small number
of participants, a retrospective nature, and lack of a control group.
However, the clinical response and improvement observed in most
of our patients is noticeable, with promising results for future utility.
In conclusion, our study demonstrates beneficial outcomes using
a new high-­fluence 1540-­nm fractional Erbium: glass laser probe
for facial rejuvenation. This nonablative high-­intensity platform can
result in a better cosmesis with no downtime and minimal adverse
effects.
(C)
(D)
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4       SOLOMON-­COHEN et al
(A) (D)
(B) (E)
(C) (F)
ETHICS
All patients included in this study have given informed consent to
treatment and to usage of clinical photos.
AU T H O R S H I P
We hereby confirm that all authors in this article: Have made substan-
tial contributions to conception and design, or acquisition of data, or
analysis and interpretation of data; and been involved in drafting the
manuscript or revising it critically for important intellectual content;
and given final approval of the version to be published. Each author
should have participated sufficiently in the work to take public re-
sponsibility for appropriate portions of the content; and agreed to
be accountable for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work are ap-
propriately investigated and resolved.
DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from
the corresponding author upon reasonable request.
ORCID
Efrat Solomon-­Cohen  https://orcid.org/0000-0003-4080-1489
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