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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