Download SR04 BitterMD.Australia

ipl
theELOS
advantage
‘The most significant advance in non-ablative
skin rejuvenation has been the introduction
of the dual mode pulsed optical and bipolar
radiofrequency device from Syneron,’ says
Dr Patrick Bitter from Los Gatos, USA.
90
A U S TR A LI AN
C O SM ET I C
SU R GE RY
ipl
technology breakthough
Intense Pulsed Light (IPL) is the new buzz word in the industry. It is based on the same principle as laser but emits a broadspectrum of pulsed light to reach several layers of the skin at once. Australia’s beach culture has created a society where sun
damage is rife and hair removal popular. IPL systems are generally considered more effective in treating these areas than older
style lasers. This is because they can be used to treat a larger area and are not as invasive so treatments can be done in a lunch
hour. Plus there is no downtime and no burning of the skin.
The Syneron ELOS sytems deliver the latest technology. US and international medical experts have publicly stated that they are
safer and more effective than the light-only machines. The combination of technologies allows for more effective removal of light
and fine hair compared with light-only systems. The Electro Optical Synergy (ELOS) Advantage or FotoFacial RF is the next
generation of the old photofacial system. Importantly, the ELOS Advantage system is approved for use on dark skin types, is less
painful for patients and causes no patient downtime.
ENHANCED NON-ABLATIVE SKIN REJUVENATION USING A DUAL MODE, INTENSE PULSED
LIGHT AND BIPOLAR RADIOFREQUENCY DEVICE – PATRICK BITTER, JR, MD
on-invasive (non-ablative) skin rejuvenation using
broad-spectrum light sources has become one of
the most popular cosmetic procedures since the
introduction of the full-face, serial treatment technique 1.
In this technique a series of five or more full-face
treatments using Intense Pulsed Light are performed at
three or more week intervals. The predictable, reproducible
visible improvement in the appearance of skin coupled with
the ease of treatments, low risk of complications, relative
ease of technique mastery, rapid results and no patient
recovery time has made this technique highly popular
amongst cosmetic physicians and patients seeking better
looking skin.
Overall improvements in photoaeging, dyschromia,
erythema, flushing, telangiectasias, rosacea, skin texture
and pores vary between 65 per cent to 90 per cent. Patient
satisfaction for these clinical indications is reported at
80 per cent to 90 per cent. A variety of patients with
skin phenotypes from I to V have been safely treated 2.
Impressive as these results have been, the degree of
improvement in wrinkling and skin laxity has been less
dramatic. In the initial report by this author, the overall
reduction of perioral, periocular and forehead rhitides was
28 per cent. This is comparable to the degree of wrinkle
reduction reported for non-ablative laser devices.
In 2002, Syneron introduced a combination broadspectrum light source with bipolar conducted radiofrequency (RF) electrical current: Electrical/Optical Synergy
technology (ELOS, Aurora, Syneron, Israel). In this system,
visible light over a 580nm to 980nm spectrum is delivered as
a single 25msec pulse, while the RF current is delivered
simultaneously over a 200msec pulse. The net effect is to
force the RF energy to stream preferentially to the regions
of the dermis pre-heated by the absorbed light, producing a
greater and more focused thermal effect than a single pulse
N
AU ST RA L I A N
C OS ME TI C
S U RG E RY
of high energy light. In theory, lower light fluences coupled
with RF energy would produce greater thermolysis of
vascular and dermal pigmented targets and greater overall
dermal collagen heating while minimising the thermal effect
on the epidermis than with pulsed light-only devices. This
paper presents some of the clinical experience to date of
this bipolar RF and pulsed light device for skin rejuvenation.
The FotoFacial procedure introduced in 1999 uses a
broad-band light source in a series of full-face treatments
to produce a global improvment in the appearance of skin,
non-invasively and without patient downtime. The results of
the FotoFacial procedure have been well described 1, 2.
Indications for the FotoFacial procedure fall into three
broad areas: 1) vascular abnormalities such as erythema,
flushing, telangiectasias and rosacea; 2) pigmentation
irregularities such as lentigines and freckling, postinflammatory hyperpigmentation and in some cases
melasma; and 3) textural irregularities such as fine wrinkling,
acne scarring and rough, porous skin.
Photoageing encompases many of these irregularities
and as such is one of the most common indications for
improvement with the FotoFacial procedure. Additionally,
skin anywhere on the body can be safely treated with the
FotoFacial procedure, allowing improvement in many
non-facial conditions such as photoageing, poikiloderma,
erythema and dyschromias for which there have been
previously limited effective options.
Contraindications to the FotoFacial procedure are skin
type VI patients, tanned skin, pregnancy and patients
taking photosensitising medications such as Roaccutane.
Complications such as superficial skin burns, purpura,
swelling and lack of results occur in one to 10 per cent of
treatments and occur most commonly with inexperienced
or untrained practitioners. Scarring with depigmentation or
hypertrophic lesions in the author's experience are very
91
ipl
rare. More than 2000 physicians have been trained to date
in the original FotoFacial procedure and more than 5000
procedures are performed each day in the USA.
FotoFacial RF is used to describe the same series of
full-face treatments using the combined optical and radiofrequency energies of the Aurora. In treatments of over
2000 patients, many of whom have had prior IPL treatments
with the FotoFacial RF procedure, and in a split-face
comparison study of the IPL FotoFacial and FotoFacial
RF conducted by the author, it has become clear that there
are five major advantages of this new technology over
Intense Pulsed Light (IPL)-only technologies: 1) better
overall clinical results; 2) patient preference for the
FotoFacial RF procedure; 3) lower incidence of complications and a greater margin of safety in treating skin type
IV and V patients and in slightly tanned patients; 4) more
rapid mastery of technique finesse with the FotoFacial RF
procedure; and 5) reduced cost per treatment.
BEFORE
AFTER non-ablative treatment with
FotoFacial RF
1 Enhanced clinical results
There is a greater degree of improvement seen in erythema,
telangiectasias (especially larger blue vessels on the nose),
and flushing with the FotoFacial RF compared to IPLalone treatments. Reduction of wrinkling is twice as much
as seen with IPL-only FotoFacial treatments (65 per cent
versus 28 per cent for class I rhytids).
There is a greater overall improvement in skin texture
and porousness of skin with the FotoFacial RF treatment.
Improvement in skin laxity, especially of lax neck skin, is
regularly reported by patients with the Aurora, while not
being a significant benefit of IPL-alone treatments.
Improvement in freckling and lentigines and overall improvement in skin colour is comparable between the two types
of treatments.
2 Greater patient preference
Patients who have received both IPL-only FotoFacial
treatments and FotoFacial RF treatments have expressed
an overwhelming preference for the latter. Three important
reasons underlie patient preference for the FotoFacial RF
treatment: 1) enhanced clinical results with more rapid
onset of visible improvement; 2) treatments are easier and
more comfortable for patients; and 3) there is a lack of
immediate post-treatment erythema, swelling and purpura
with the FotoFacial RF procedure. Most patients find the
FotoFacial RF treatments to be easier with little or no
92
immediate post-treatment erythema. No purpura occurs
with Aurora treatments as opposed to a up to 20 per cent
incidence of post-treatment purpura with IPL devices.
3 Lower incidence of complications
There is considerably less likelihood of post-treatment
swelling and erythema with FotoFacial RF treatments.
There is no post-treatment purpura. Epidermal burns from
high optical fluences or the filter in too close a contact with
the skin are almost completely eliminated with the Aurora.
The Aurora uses two different energies, broad-spectrum
optical and radiofrequency electrical current, each of which
can be controlled independently. This permits the
practitioner to select lower light energy fluences while using
maximum RF energy. Thus an effective treatment can be
performed while minimising the risk of superficial burns to
the epidermis, one of the most common complications
associated with IPL treatments. In addition, the light is
BEFORE
AFTER non-ablative treatment with
FotoFacial RF
pulsed over a 25msec duration, which is much longer than
the most commonly employed IPL systems. A longer pulse
duration helps to limit the degree of epidermal melanin
heating, also reducing the risk of epidermal burns.
Additionally, the Aurora has two features that decrease
the risk of epidermal burns: a chilled electrode tip and
dynamic dermal monitoring. By pre-cooling the epidermis,
the RF energy is forced to pass more deeply into the dermis
as electrons flow from one electrode to the other. This has
two beneficial results: firstly, superficial burns are minimised
and secondly, more effective dermal heating produces a
greater clinical result on vessels and dermal collagen.
With active dermal monitoring, there is a built-in safety
feature of the Aurora that permits the operator to preselect
the level of change in impedance that will be allowed. By
preselecting the Impedance Safety Level (ISL) the degree of
dermal heating is controlled. Each pulse records the
change in impedance. The more easily the electrons flow
between the two electrodes the greater the change in
impedance measured and the greater the rise in skin
temperature. This feature makes treatment of skin types IV
and V patients and patients with some degree of tan much
safer with a lower risk of epidermal burn then IPL systems.
Additionally, patients with melasma are less likely to
experience a worsening of their dyschromia with the
Aurora, whereas this occurs in up to 50 per cent of IPLalone treated patients with melasma. Active Dermal
A U S TR A LI A N
C O SM ET I C
SU R GER Y
ipl
Monitoring gives the operator one additional valuable piece
of information with each pulse that is not available with IPLonly devices to help further ensure that the selected
parameters are producing an optimally effective treatment;
a benefit the new practitioner immediately appreciates.
Finally, because the technique is more easily mastered
with the Aurora, delegation of the FotoFacial RF
treatments to other medical staff is less likely to produce
complications than may be seen with the novice
practitioner and IPL systems.
With any light-based non-ablative device, clinical results
do depend on a mastery of technique finesse. The most
common ‘complication’ of IPL rejuvenation treatments is
a lack of result. This may be seen because of selection of a
patient with unrealistic expectations, or failure to perform
enough treatments. The most common reason for lack of
result is a lack of proper treatment technique. As discussed
below, the FotoFacial RF procedure is much easier to
master than IPL-only rejuvenation procedures. In the
initial series of 49 patients undergoing a series of five
FotoFacial procedures the dissatisfaction rate was 12 per
cent 1. In a series of 108 patients treated with the
FotoFacial RF procedure the patient dissatisfaction rate
was only five per cent.
It is important to note that because of the additional
electrical energy of the Aurora there is a risk of electrical
burn to the epidermis if the electrodes do not make
adequate contact with the skin. Most such burns are very
superficial in nature and appear as very thin linear crusts
the day after treatment. These resolve in three to five days.
Deeper burns may occur very rarely and can heal with a
shallow depression that usually responds to additional
FotoFacial RF treatments. With experience these
inadvertent electrical burns are largely preventable.
4 Ease of mastery of technique finesse
One of the disadvantages of non-ablative light-based skin
rejuvenation is that results are very dependent on technique. Technique mastery has been one of the most difficult
challenges of IPL skin rejuvenation, with a lengthy learning
curve sometimes required.
With the FotoFacial RF procedure the electrode of the
Aurora's hand piece is placed in direct contact with the skin,
eliminating the guesswork involved in judging the exact
distance of the crystal from the skin, making the technique
much easier to master and producing much more even
and consistent results from treatment to treatment and
between operators.
Treatments with the Aurora do not require a coupling
gel, only a thin layer of a non-gel aqueous solution. Thus,
thick layers of coupling gel are eliminated, making the
treatment neater and more pleasant for the patient.
5 Reduced cost per treatment
While not affecting the clinical outcome, operation of the
Aurora is at a cost of 25 to 50 per cent lower than some
A U ST RA LI A N
C OS ME TI C
S U RGE RY
commonly used IPL devices. A significant factor in the cost
per treatment is the cost of maintaining the device and any
disposable costs such as hand pieces. Considering that
each xenon flash lamp has a finite life and eventually needs
to be replaced at a cost of US$3000 or more and that one
treatment session could run 100 to 250 pulses, the added
cost of each treatment for the hand piece alone can be
US$25 to $50. In addition, maintaining a service contract
on each device can be quite costly and may add as much
as US$10 to $25 of additional cost to each treatment. Each
of these added costs to perform a treatment are eliminated
in the first three years of operation of the Aurora. This can
translate into a savings of as much as US$20,000 per year.
Conclusion
One of the most popular and rapidly expanding areas of
aesthetic medicine is non-ablative skin rejuvenation
procedures using laser or light-based devices. These nodowntime procedures have become very popular with
patients as a way to improve the appearance of photoaged skin and generalised erythema as well as wrinkles.
Patients find the natural results and ease of treatments very
desirable as an alternative to more aggressive treatments.
These procedures have become very popular with a
wide variety of patients from younger patients desiring
more attractive skin, to middle-aged patients who desire to
look better without surgery and aesthetic surgery patients
who want to enhance their surgical result. It is popular for
patients to refer friends and family members for treatments
or to add other areas such as the chest, hands, forearms,
etc because of the ease of treatments and degree of visible
improvement seen. Men in particular find the FotoFacial
RF procedure appealing because of the lack of stigma that
a cosmetic surgical procedure may entail and because it
does not look obvious to the world that a cosmetic
procedure was performed.
With technological advances, results have become
better and outcomes more predictable and consistent with
fewer complications. The most significant advance in nonablative skin rejuvenation has been the introduction of the
dual mode pulsed optical and bipolar radiofrequency
device from Syneron. The Aurora produces results superior
to that seen with IPL-alone devices with a greater margin of
safety and at a lower cost per treatment. The Aurora
introduces the next generation of non-ablative devices and
a new concept in light/skin interaction: Selective RadioPhotoThermolysis. This concept more accurately describes
the interaction of the dual energies of light and electrical
current on tissue. The future of skin rejuvenation lies in the
successful ability to combine different energies for
enhanced results. The technology from Syneron has taken
the next big step in this direction. acsm
References
1.Bitter PH: Non-invasive rejuvenation of photodamaged skin using serial, full-face
Intense Pulsed Light treatments. Dermatol Surg 2000; 26: 835-843.
2.Negishi K, Tezuka Y, Kushikata N, Wakamatsu S: Photorejuvenation for Asian skin
by Intense Pulsed Light. Dermatol Surg 2001; 27(7): 627-32.
93