The new slogan for the paradigm shift currently taking place in wrinkle removal could be "less invasive, still effective." Technological, pharmaceutical, and medical advances are allowing physicians to achieve good skin texture and prevent aging with less-invasive treatments and, increasingly, more patient involvement.

"As in every other area of health care, prevention and prophylaxis are key," said Brooke Seckel, M.D., chief of Lahey Clinic's cosmetic and laser surgery center (Burlington, MA). "Just as physicians ask people to eat the right diets to avoid colon cancer, (we) can advise patients how to manage their skin today to avoid surgery when they are 60 years of age."

With the advent of several new wrinkle-removal technologies and techniques - including dermal peeling Botox injections, new lasers and glycolic acid peels - Seckel says he is performing far less traditional CO2 or Er:YAG laser resurfacing compared to one year ago. In fact, he no longer recommends the CO2 laser to most of his patients; instead, he suggests they see his aesthetician, have microdermabrasion, and then begin glycolic acid peels and a skin care regimen.

"Most of my practice is becoming nonsurgical because we now have technology that achieves good results and allows patients to go on with their lives without enormous wound healing," he says. "Of course, patients must be willing to invest six months to a year to see results."

Seckel presented one-year results from a study of 200 patients treated at three sites with a nonablative laser approach for skin resurfacing at the annual meeting of the American Society for Aesthetic Plactic Surgery earlier this year. He noted that the 1320nm laser from Laser Aesthetics (Auburn, CA) is an adjunct to the newer peeling procedures that removes dead skin and stimulates new epithelial proliferation and new collagen production.

"This laser is a faster and more thorough stimulator of collagen production and fibroblasts than topical agents, but doesn't damage the skin like the CO2 and Er:YAG laser so there's no downtime," he says.

Unlike the CO2 laser, whose target is water in the epidermis, the 1320nm Nd:YAG laser is designed to be absorbed selectively in the dermis. This wavelength penetrates easily through the epidermis and is uniformly absorbed in hydrated tissue. In addition, the high scattering coefficient causes the light to "bounce around" the upper dermis and lose its energy before penetrating to deeper layers, according to Laser Aesthetics.

The ability to pulse the energy source further limits the spread of thermal energy by conduction. This new laser delivers up to 30J/cm2 of 1320nm energy within 20 microseconds. This causes significant heating of the upper dermis (up to 70 degrees C) with minimal collateral heating.

"This laser is designed to injure and thus stimulate fibroblasts in the dermis," Seckel says. "Long term results with the CO2 laser have shown that the thermal injury causes stimulation of dermal fibroblasts, and this process creates new collagen."

Data Encouraging

The question is, can new collagen be created without creating a massive superficial injury? Seckel believes that this is possible; the wound healing creates new collagen through stimulation of fibroblasts, and the wavelength is designed to pass through the epidermis without injury to the fibroblasts in the dermis. In his study of the new laser he reported on at the American Society for Laser Medicine and Surgery meeting, at one year, fibroblasts were consistently stimulated resulting in the production of new collagen in the dermal layer of the skin. Clinical evaluation of the patients showed that the treated lines and wrinkles in the perioral and periocular area were softened by 15% to 25% and that the treated areas remained red for only one to twelve hours after the procedure. Six patients required two weeks to heal from epidermal burns.

"There is documented histology that shows new collagen formation, fibroblast proliferation, and improvement of wrinkles," he says. "The CO2 laser can achieve 70% improvement in wrinkles; however, the response seen with the 1320nm Nd:YAG laser is less dramatic - a 15% to 25% improvement."

In fact, although no anesthesia is used, patients do not complain of pain, and there is no need to prep the skin. The trade-off is that patients will not see results for about six months after treatment. The best candidates are those who are just beginning to have fine wrinkling in the perioral and periocular areas and those who have already had a CO2 or Er:YAG procedure and want further wrinkle reduction.

"It is ideal for younger patients who want to maintain their youthful appearance and perhaps delay plastic surgery," he says, adding that he suggests patients have the 1320nm Nd:YAG laser procedure and microdermabrasion at the same time. While this leaves the skin slightly pink, it allows them to return to work immediately.

The treatment itself is time-consuming because the spot size is small, 9 to 12mm, and the operator must carefully lay down spots to avoid overlap. The procedure does not require anesthesia because coolant squirts out of the handpiece onto the skin, and the laser fires a microsecond later. Success, according to Laser Aesthetics, hinges on balancing the thermal aspect of the laser - wavelength, waveform, and radiant exposure - with the protective cooling of the epidermis prior to the application of laser energy.

More Research Needed

The noninvasive approach requires additional investigation to evaluate its safety and efficacy, Seckel notes, and studies are underway to further develop additional devices and the technique itself. Even so, he prefers this less-invasive treatment for several reasons, including the fact that it gives patients and physicians the opportunity to explore another treatment modality.

"I don't like to burn faces; it traumatizes the patients and me," he says. "Using this method for facial rejuvenation allows me to concentrate on what I do best: plastic surgery - blepheroplasty, facelifts, and breast augmentation."