EADV 2024: Tips & Tricks in Combination Therapy for Facial Rejuvenation
Speaker- Ashraf Badawi
Rejuvenation is when the aim is to restore the skin's structure and function. However, it is called a quick fix when the objective is to improve skin appearance without addressing its underlying issues. Available tools include toxins for dynamic wrinkles, fillers for volume loss, contour and shaping and laser and energy-based devices for collagen stimulation, tightening, treatment of scars, pigmentation and vascular issues. Often, a combination of these tools is necessary. Finally, understanding the underlying pathology and the interaction of each tool with that pathology is crucial, as misapplication could lead to ineffective outcomes.
There has been a need to differentiate between rejuvenation and quick fixes. While using botulinum toxins effectively eliminated dynamic wrinkles, it did not constitute true rejuvenation. As the effects wore off, patients faced the consequences of aging, often finding their skin in worse condition than before if no efforts were made to improve its structure and function. Hence, a comprehensive approach to skin health beyond temporary solutions is vital.
The skin is composed of three layers: the epidermis, dermis, and subcutaneous fat and tissue. Each layer has distinct structures and functions that contributes to the skin's appearance. With aging, disturbances in these structures affect their functions, leading to visible manifestations of skin aging.
In many cases, patients reported concerns that extended beyond the skin's surface. It was observed that the epidermis was often impaired, compromising the epidermal barrier function. This impairment negatively impacted the skin's appearance and affected the outcomes of treatments if it was not addressed.
Rejuvenation involved achieving five cosmetic targets: improving skin condition and removing skin damage, stimulating cell division, ensuring skin nutrition, enhancing cell functions and providing anti-aging protection. The first three targets can be addressed through procedures that improved skin condition and removed damage, often stimulating cell division. However, the remaining two targets might require patient involvement; through enhancement of their nutrition, increased water intake, and use of appropriate skincare products. Without their commitment, the efforts would remain incomplete.
At the epidermal level, it was crucial to enhance the epidermal barrier function by replacing the damaged epidermis from photoaging and hyperkeratosis with a healthier one. This improvement significantly impacted the skin's appearance. In the dermis, addressing elastosis was essential, as collagen loss began around age 20, with areas exposed to light experiencing double the loss. Stimulating new collagen formation was necessary not just for scarred areas, but across the entire skin surface, especially where skin laxity was present. Patients often were unaware of these issues and did not specifically mention skin laxity; for example, a late-30s acne scar patient might not request skin tightening. It was the practitioner’s responsibility to identify and address skin laxity to optimize the treatment of acne.
The options for rejuvenation included various modalities. Topical preparations encompassed chemical peels, microdermabrasion, and hydrodermabrasion, which mechanically improved the epidermis. Tissue augmentation utilized different agents, while toxins addressed dynamic wrinkles and lines. Skin needling, with or without fractional radiofrequency, emerged as a notable treatment. Tissue tightening involved radiofrequency, infrared light, and lasers, including non-ablative laser rejuvenation. Surgical options included minimally invasive procedures like thread lifting and traditional surgery. Each modality targeted specific layers of the skin, which was crucial for effective treatment planning. For instance, microneedling was often mistakenly thought to enhance the epidermal barrier function, but true improvement required chemical or mechanical peels. Similarly, non-ablative laser rejuvenation did not tighten skin; deep tissue heating was necessary. Understanding the specific layers each treatment affected remain essential for developing a successful rejuvenation plan.
Three-dimensional rejuvenation was essential for effective treatment, addressing the epidermis, dermis, and skin laxity in every patient, regardless of their specific concerns, such as large pores, acne scars, fine lines, or pigmentation. Improving the epidermal barrier function remain fundamental. For the dermis, collagen induction therapy was essential to stimulate collagen production not only in scarred areas but across the entire skin surface. If skin laxity was present, tightening treatments were also required. To improve the epidermis, there are several options, including retinoids, chemical peels, microdermabrasion, and laser peels. For stimulating collagen in the dermis, tools included skin needling, microneedling with radiofrequency, and various types of lasers, such as non-ablative and ablative fractional lasers, along with Platelet-rich plasma (PRP) injections to enhance collagen synthesis. For skin tightening, options include radiofrequency, infrared light, lasers, high-intensity focused ultrasound (HIFU), thread lifting, and surgical procedures. Hence, it was crucial to understand each modality and combine treatments based on the patient's specific pathology and the layers of skin needing attention. A common mistake observed was a limited approach, where patients with acne scars often received treatments focused solely on the dermis, neglecting the epidermis and skin tightening. Targeting all layers of the skin remain vital for achieving optimal outcomes.
Collagen reduction therapy is a non-ablative rejuvenation method aimed at stimulating collagen production. Various approaches can be utilized, particularly through lasers. Effective targeting required addressing both hemoglobin, to heat the upper vascular plexus without causing damage, and water, to heat the upper dermis. This process induced acute inflammation, attracting fibroblasts, which synthesized new collagen. The 1064 nm wavelength was notable because it could be absorbed by both hemoglobin and water, making it an optimal choice for non-ablative rejuvenation. Previous attempts with non-ablative lasers often focused on either hemoglobin or water separately, such as with pulsed dye lasers (PDL) or wavelengths like 1550 and 1440 nm. This made 1064 nm particularly effective for achieving desired rejuvenation outcomes.
The study published in the Journal of Laser Surgery and Medicine began with microdermabrasion to enhance the epidermal barrier function. Four weekly sessions using an older diamond peel method, which mechanically removed corneocytes while stimulating local blood circulation and lymphatic drainage were done. This was followed by neodymium-doped (Nd: YAG) laser treatments, employing parameters of a 6- or 9-mm spot size, 10 to 15 joules, and a short pulse duration of 0.3 to 0.6 milliseconds, with a frequency of 5 to 10 hertz. The goal was to raise skin temperature to 42-43 degrees Celsius for three minutes without the use of cooling or anesthesia, making the treatment tolerable. The protocol included three monthly laser sessions in conjunction with the four weekly microdermabrasion sessions, effectively targeting both the epidermis and dermis. The results were outstanding, demonstrating improvements not only in acne scars but also in overall skin rejuvenation for skin types five and six, with no downtime, complications, or pain associated with the treatment. Within three months, significant texture improvements were reproducibly observed.
Acne scars could be effectively treated with non-ablative rejuvenation, provided that measures were taken to improve the epidermis. Outcomes from non-ablative fractional lasers demonstrated significant improvement in acne scars, similar to results seen with ablative fractional resurfacing lasers. For those without access to lasers, microneedling is a valuable option, also yielding impressive results. However, successful outcomes in all modalities required a combined approach that included enhancing the epidermal barrier function. Additionally, in cases of skin laxity, tightening treatments were necessary to address all layers of the skin effectively.
When the right combination of treatments was applied, remarkable results were achieved. In cases with three years of follow-up, patients exhibited significant improvements in skin appearance despite aging. The same patients showed marked reduction in elastosis, demonstrating the effectiveness of the treatment protocols. For patients with combined pathologies, a multifaceted approach was utilized. Treatments included microdermabrasion to enhance the epidermal barrier function, microneedling with radiofrequency for collagen stimulation, and non-ablative rejuvenation with laser and radiofrequency (RF) for skin tightening. The outcomes were visibly positive, with noticeable improvements in skin health and appearance achieved easily in a single session.
Lip rejuvenation was approached using lasers to stimulate collagen, enhancing both the collagen content and contour of the lips. This method offered the advantage of avoiding overcorrection, a common issue with fillers. Instead of simply filling the lips, laser treatment aimed to rejuvenate them by improving their structure and function. Starting in 2019 and continuing through 2022, patients demonstrated significant improvements in lip appearance without the use of fillers. The results focused on the effectiveness of collagen stimulation for achieving youthful, natural-looking lips.
A study began implementing "prejuvenation" for patients, including younger individuals seeking to prevent signs of aging. After completing a series of treatments, these patients participated in an anti-aging program that involved three to four clinic visits for a combination of procedures. The approach had the advantages of minimal downtime and reasonable costs when spread over the year. Expectations were set to focus on maintaining healthy, youthful skin, with the goal that patients would look the same or even better in ten years.
Whether the combination treatments of injectables and energy-based devices could be performed on the same day. Several studies indicated that skin rejuvenation often benefits from a combination of techniques, including lasers, intense pulsed light (IPL), radiofrequency, botulinum toxins, and fillers. While a combined approach was deemed optimal, same-day treatments were typically avoided due to concerns that lasers might inactivate or degrade the injectables. Consequently, lasers were usually administered prior to filler or toxin injections.
Another review of the literature on combination treatments involving RF, IPL, non-ablative and ablative lasers, along with fillers or botulinum toxins, revealed 15 studies. Seven studies assessed combined light system treatments with fillers, while eight examined physical therapies with toxins, all adhering to standard protocols. Notably, six studies documented no histological changes in fillers injected after RF, IPL, or laser treatments. Additionally, one study reported collagen improvement following IPL treatment and toxin injections. Overall, these studies indicated clinical enhancements in various features of photo-damaged skin, with no increase in adverse effects or reduction in the efficacy of the injected substances. In conclusion, the literature review demonstrated that same-day combined treatments for rejuvenation were safe and resulted in improved clinical outcomes. These approaches were more comfortable for patients, showed no loss of efficacy, and did not present any apparent adverse effects.
Another study explored the concomitant use of hyaluronic acid (HA) and laser facial rejuvenation, confirming that the combined procedure could be safely performed on the same day. The panel recommended initiating treatment with the light procedure and advised against skin manipulations after HA injections. Customizing therapeutic management was deemed essential, requiring a precise diagnosis of the photo damage and volume loss experienced by patients.
In conclusion, the current scientific evidence regarding the combined use of HA fillers and laser treatments, including radiofrequency and intense pulsed light, was limited, primarily consisting of small and non-randomized studies. However, most studies indicated that the concomitant use of lasers and HA fillers for facial rejuvenation was both effective and safe, improving clinical outcomes and patient satisfaction. Future well-designed clinical studies are necessary to further evaluate the effectiveness and safety of these combination treatments.
33, European Academy of Dermatology and Venereology Congress, 25-28 September 2024, Amsterdam.Top of FormBottom of Form
