Anti-Ageing Conference, London 2012 · Fractional Ablative Lasers and Micro-plasma Radiofrequency in Skin Rejuvenation. Anti-Ageing Conference, London 2012. Maria Angelo-Khattar M.D.,

Fractional Ablative Lasers and Micro-plasma Radiofrequency in Skin

Rejuvenation

Anti-Ageing Conference, London 2012

Maria Angelo-Khattar M.D., Ph.D.Aesthetica Clinic

Dubai

Life Expectancy Chart from 1850-2000

Strong Shift Towards Minimally-Invasive Procedures

Pre-1992 : Aesthetic Corrections were mainly Surgical

1992: Jean and Alistair Carruthers published the firstpaper on the Cosmetic Use of Botulinum Toxin

(Procedures in millions)

0.0

4.0

8.0

12.0

6.0

10.0

2.01.0M1.1M

1.9M

9.5M

1997 2006

Non‐

Invasive ProceduresInvasive Procedures

0.0

4.0

8.0

12.0(Procedures in millions)

6.0

10.0

2.0

1997 2006

Growth Rate = 98%

Growth Rate = 747%

Source: The American Society for Aesthetic Plastic Surgery, March 2007

Minimally-invasive procedures account for majority of growth Minimally-invasive procedure = 83% of market

Strong Shift Towards Minimally-Invasive Procedures

Tightening

Texture

Tone

Colour

Skin Refining with Ablative Fractional Lasers and Radio-frequency Devices

Courtesy of Aesthetica Clinic

P.J. 57 years old:Five

months post

vertical face lift

Aesthetic Treatments

Skin Care Regimen:-Sun protection-cosmeceuticals

Hormonal Optimisation

Avoidance and Elimination of toxins

Lifestyle:DietExerciseSleepStress controlRelationships

Nutrition and supplementation

ANTI

AGIN

G P

RIN

CIPL

ES

Keith RichardsThe Rolling Stones

Inhibit leucocyteelastase

Decrease elastin degradation

Increase elastindeposition

ELASTOSIS

PHOTO AGEING

Extrinsic AgeingUV exposure

Intrinsic AgeingOxidative Metabolism

Suppress TGF-BetaReceptor 2

Degrade antioxidants

Suppress pro collagensynthesis

REDUCTION IN DERMALCOLLAGEN LEVELS

Degrade collagen

Activate MMP

Active AP-1

Increase ROS

InduceInflammation

Activate NF-Kappa B

Dermal Atrophy and Loss of Normal Architecture • Impairment of the micro- circulation

• Cellular degradation: mainly fibroblasts

•Collagen fibre degradation via MMP-1 induction

- Loss of collagen integrity• Elastosis

-Loss of elasticity• Extra-cellular matrix degradation

•Subcutaneous fat resorption and redistribution

-Volume Loss

Collagen degradation: ‘young’ vs ‘old’

24 years old 48 years old

Elastica von Giesson staining

Elastosis: degeneration of elastin fibers

26 years old 66 years old

Specific immuno-elastin staining

Physical Aging is Optional

Keith Richards Born in 1943 Robert Redford Born in 1936

Who is the mother and who is the daughter?

What Characterises a Youthful Appearance?

Young Skin is Bright SkinA Young Face is Full Face

Skin Peels

Mesotherapy/ Microneedling

Fractional Ablative Laser Resurfacing

Non-Ablative Photo- Rejuvenation

Full Laser Resurfacing

Carbon Dioxide and Erbium YAG lasers

Effi

cacy

Skin Refinement and Rejuvenation: Basic strategy follows the principle of “Controlled

Wounding…”

Wound Healing ReactionWound Healing ReactionWound Healing Reaction

Injury

AntioxidantsRetinoic acid/ retinol

Retinoic acid/ retinol

Healing and remodeling of skin damaged by the effect of intrinsic aging, extrinsic aging, wound or laser procedures

Intrinsic AgeingOxidative Metabolism

Inflammation leading to ROS Mediated ECM Degradation

Wound

TGF BetaPDGFVEGFIGFFGF 2IL8

Laser Procedures

Intrinsic AgeingOxidative Metabolism

ECM Formation Woud ClosureRe-epithelialisation

Dermal Remodelling

TGF betaFGF 2TIMP’sMMP’s

Lasers and Energy Based Devices can ….

Improve the appearance of Aged Skin

Reverse the signs of Skin Aging

Delay Skin Aging

Reduce the risk of Skin Cancer?

Full Laser Skin Resurfacing

69 year old: before and after full face skin resurfacing Courtesy Dr. Susan M Hughes MD

Deep, partial-thickness skin resurfacing requires intensive topical therapy and may be characterized by the following risks:Acute:– Risk of surface yeast, viral and bacterial super-infection– Re-epithelialization in cases of superficial peels requires at least 8-10 days ,

in deep peels approximately 3 weeks.

Sub-Acute:- Patient remains erythematous for 6 weeks to 3 months and in some casespermanent redness may result.

Long term complications: – Permanent hyper-pigmentation, hypo-pigmentation and scarring may

occur. – Lines of demarcation– Sunlight hyper-sensitivity from half-year to a year.

Traditional Laser Resurfacing Complications

……requires downtime requires downtime

Must protect from sun exposure!Immediate and prolonged weeping, oozing, redness

Patients want results but no down-time!

From Bulk to Fractional

Introduction to Ablative Fractional Resurfacing

Creation of microscopic channels in the skin interspersed between normal tissue

DERMIS

EPIDERMIS

Ablative Fractional Resurfacing

Ablative Fractional Resurfacing Options

Fractional Ablative LASERS:Er: YAG Laser

CO2 Laser

Fractional Ablative Radiofrequency Plasma Technology

•• Ablation Ablation ––Vaporization shrinks the epidermisWhen the epidermis is ablated, there is a reduction of

dyschromia and even precancerous lesions

•• Thermal effectThermal effect –– heat the upper dermis promotes :heat the upper dermis promotes :

Denaturation of ExtraDenaturation of Extra--cellular matrix proteinscellular matrix proteins

Immediate contraction of collagen exposed to temperatures Immediate contraction of collagen exposed to temperatures above 60above 60oC

Deposition of new collagen Deposition of new collagen

Reorganisation of the dermisReorganisation of the dermis

Two Skin Renewal Mechanisms

Mechanism of Action of Ablative Fractional Resurfacing

Ablative Fractional LasersCO2 and Erbium:YAG lasers

Mechanism of Action

Relative Absorption of Er:YAG and CO2 lasers

CO210,600nm

Erbium is highly absorbed by waterAnd therefore the thermal injury Is lower than with CO2.

Erbium 2940nm

Laser Skin Interaction

Fractional CO² and Er: YAG work by applying the laser energy through holographic lenses that pixelate the beam to microscopic beams or pixels on the surface of the skin.

How are the CO2 and Er: YAG laser beams fractionated

Non-injured

Injured

Fractional Er: YAG Skin Manifestations

Lasers in Surgery & Medicine, March 2008

Moshe Lapidoth MD, MPH. Marina Emiko Yagima Odo, MD, Lilian Mayumi Odo.

Novel use of Erbium:YAG (2940 nm) laser for fractional ablative photothermolysis

in the treatment of photodamaged facial skinA pilot study

6-134Dermatol Surg, 2008

Publications

Mario A. Trelles & Serge Mordon & Mariano Velez &Fernando Urdiales & Jean Luc Levy Lasers Med Sci2008

Skin Before and Two months after a single treatment with Fractional Er:YAG

Ablative Unipolar Radiofrequency Plasma Technology

The treatment technique may be either Stationary and In-motion due to two separate handpieces

RF Application Technique

2. Transdermal drug delivery with Ultrasound hanpiece

1. Plasma Ablation with unipolar RF

Plasma

• Plasma state is the fourth state of matter• Plasma is a state of matter in which electrons are

stripped from atoms to form an ionized gas.

+

+

++

- +

+ +

+

-

-

-

--

- --

Solid

Liquid

Gas

Plasma

EnergyEnerg

y Energy

• The electromagnetic RF energy excites gases in the air such as nitrogen and produces Plasma, thus forming micro-sparks between the skin and the RF electrode.

• These sparks ablate and perforate the skin

• This produced micro-channels, their depth and diameter depend on duration of pulse of RF-energy and RF-power.

RF Energy

Plasma

Skin

Plasma Skin Interaction

RF Fractional Ablation results in Microscopic Ablated and Coagulated Tissue Channels

• Porcine Skin• Depth and diameter depend on Power and Pulse

duration– 100-150µm in depth and 80-120 µm in

diameter

Day 0 Day 3 Day 14

Photo Courtesy: Arie Orenshtein, M.D, Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel Hashomer, Israel

Pre-Clinical Studies

Ablative Fractional Skin Resurfacing Indications and Clinical Protocols

Improvement in Skin Surface Texture

Clearance of Photo-damaged skin/ Dyschromias

Reduction in Perioral and Periorbital rhytides

Reduction of Pore size

Post-acne scarring

Treatment of Surgical and Post traumatic

Clinical Indications

Contraindications

Dermatological Conditions: Dermatitis, AllergyHaving taken Isotretinoine within the past 6 months History of Cancer or Autoimmune DiseasePregnancyHistory of poor wound healing and keloid formationDemonstrate prolonged erythema, hyper- pigmentaion or hypo-pigmentation upon patch test

Patient Preparation

Emla cream with occlusion for fourty minutes

Nerve blocks

Infiltration anaesthesia

Post Treatment Sequelae

For 5-7 Days

Redness

Swelling

Crusting

Prolonged Erythema following aggressive treatments

Before Day 1 Day 2

Recovery Time Frame After Fractional Laser

Day 3 Day 4 Day 5

General Pre/ Post Treatment Care

1. Antiviral Medication: Valciclovir 1gm every 12 hours for one day

2. Topical Antibiotics: Fucidic acid cream twice daily for two days

3. Topical Steroid:

• 1% Hydrocortisone cream twice a day ( skin types IV, V and VI)

4. Depigmenting cream as of Day 4 for four weeks

1.Growth Factors: Platelet Rich Plasma and Proprietary growth factors

2.Vitamin C (10%) solution

3.Depigmenting Complex ( Arbutin, Retinyl Palmitate, Ascorbyl Palmitate, Azelaic acid, Phytic acid)

Trans Dermal Solutions

•A group of proteins that stimulate the growth of specific tissues.

•Some Growth Factors are similar to hormones in that they can be secreted into the blood stream and carried to target tissues.

•Growth Factors can be produced by many different tissues and cells in the body ( unlike hormones produced by glandular tissue). Can be produced by macrophages, platelets, fibroblasts, etc…)

•Chemical messengers between cells

•Turn a variety of cellular activities “on” and “off”

•Increase blood supply and cell recruitment

•Increase the rate at which cells in the body grow

•Involved in cell division, new cell and blood vessel growth and collagen and elastin production

What are Growth Factors?

Stem Cell Division and Differentiation

1. Growth FactorsAutologous Platelet Rich

Plasma

An autologous concentration of platelets in a small volume of plasma.

Number of Platelets in Whole blood is 200,000 / µl

Therapeutic enriched Platelet count is around 1,000,000 platelets/ µl . This concentration of platelets in a 5-ml volume of plasma is now recognized as being the working definition of therapeutic enriched Platelet rich plasma.

includes 3 proteins in blood known to act as cell adhesion molecules: fibrin, fibronectin & vitronectin

Clinical Uses: Plastic Surgery, Oral Surgery, Orthopaedic Surgery

What is Platelet Rich Plasma?

Contain growth factors

Contain serotonin, ADP and calcium

Platelet

– PDGF– TGF-b– VEGF– EGF– IGF– PF4– PDAF– Osteocalcin,osteonectin,

Fibrin, vitronectin, fibronectin and thrinombospondin

Platelet Derived Growth Factors

Increases fibroblast migration, proliferationPromote production of extracellular matrixPromote angiogenesisShown to enhance healing of chronic

wounds; shown to be absent/decreased in non-healing wounds

Pharmacological Action of Growth Factors

Action of Platelets at Injection Site

• Sterile closed System

• Enriched platelets 4- 5 times baseline concentration

Preparation of PRP using a proprietary kit

Centrifuged for 10 minutes at 3000 RPM

GEL

One tube yeilds approx. 6 ml of PRPOne tube yeilds approx. 6 ml of PRP

Preparation of PRP using a proprietary kit

Proprietary Growth Factors ( Fibroblast culture medium)