Combination Treatment Focused on a Noninvasive Approach to Facial Rejuvenation

Patients present with requests for certain procedures, and sometimes devices by name, often not realizing what procedures are best for certain issues. When we evaluate a new patient, we hand them a mirror and outline a course of options. Sometimes surgical consults are suggested, but we normally confine our options to noninvasive nonsurgical interventions and have created a recipe that addresses common facial concerns. Most patients who benefit from this 15-minute procedure range from ages 45 to 65.

The series of treatments addresses six courses of action: broad pigment dyschromia (intense pulsed light, or IPL), discrete pigmented lesions (pico or ns technology, 532 nm or 755 nm), 1927 nm fractional laser for broad low contrast dyschromia, vessels (PDL or KTP laser), crusty papules (CO2, erbium YAG, or hyfrecation), and radiofrequency microneedling (RFMN) along the lower jawline for laxity and jowls.^1,2

METHODS

Photodamage presents with diffuse and discrete dyschromia, vascular ectasia, crusts, and Venetian blind type folds/jowls in the cheek area. Although IPL alone will brighten the skin, low contrast lesions—that is, those spots with minimal contrast between the lesion and background skin—are often persistent. A nano or picosecond laser, such as the 532-nm PiQo4 from Lumenis, 532-nm PicoLO from LaserOptek, or 755-nm Alex TriVantage from Candela, treats focal low-contrast lesions to enhance the action of IPL. Even after treatment of pigment dyschromia with visible light technologies, patients with broad mottled discoloration will benefit from a 1927 fractional approach, such as the Fraxel DUAL from Solta Medical, the Lutronic from LaseMD, or the Moxi from Sciton. This fractional procedure decreases the likelihood of a frequent complaint in patients with low-contrast lesions: that the IPL or other laser “did not work”, or that lesions were “missed.”^3,4 Another concern is slightly pigmented or unpigmented keratoses, both actinic and seborrheic, which often do not respond completely to non-ablative interventions. Here, more destructive approaches are normally required, such as using a CO₂ laser, Er:YAG laser, or electrosurgery. Examples of CO₂ lasers include UltraPulse from Lumenis and DEKA DOT from DEKA. Examples of Er:YAG lasers include the Contour TRL from Sciton, UltraClear from Acclaro, and Fotona4D from Fotona. Sometimes, one can stack pulses with a picosecond or nanosecond 532- or 755-nm laser and achieve some improvement of raised pigmented lesions, but typically, a portion of the lesion will persist after peeling and crusting for 7 to 10 days.

We present a six-part device algorithm for patients with common facial concerns. We have not included neuromodulators for upper face wrinkles, or fillers for lower face volume and folds, although certainly they could be included in the algorithm. Normally if we were to add fillers, we would do those the same day. Neuromodulators typically would be done a different day to avoid edema-induced diffusion of the neuromodulator on the upper face. Of note, at least two articles have addressed possible interactions between filler and radiofrequency microneedling.^5,6 Our position has been that, although filler certainly can be focally damaged by the hot-tipped needles, on a total volumetric basis, the percent of filler damage would be quite small and not clinically relevant.

The patient in Figure 1 presented with multiple lentigines, mild vascular dyschromia, a few crusty unpigmented papules, and Venetian blind type folds in the cheek area. Just before treatment, we show the patient a series of pre- and postoperative photographs as well as interval photographs that narrate the recovery process. After a 5% numbing cream is applied for 1 hour, we begin with an IPL device (options include the Icon from Cynosure, M22 from Lumenis, Nordlys from Candela, and BroadBand Light [BBL] from Sciton), working as aggressively as possible to address excess pigment while sparing the background surrounding skin. In men who have pigmented hair on the face, because of the risk of damage to the hair follicle, we avoid IPL in that region and rely on our fractional lasers and pico/nanosecond lasers for pigment improvement. Next, we address focal lower contrast lesions with a nanosecond 755-nm or picosecond 532-nm laser with settings ranging from approximately 8 to 14 J/cm² with a 3- and 2-mm spot size for an ns alexandrite laser, and about 0.2 to 0.5 J/cm2 with a 3 to 4 mm spot size for the ps 532 nm laser. In all cases, the endpoint is a very slight whitening. Figure 2 shows treatment and the heavier darkening where discrete lesion treatment was applied with an ns or ps technology.

Figure 1A. Patient prior to treatment.

Figure 1B. Patient 3 days after treatment with combination laser recipe.

Figure 1C. Patient 14 days after treatment.

We follow with a 595- or 532-nm long pulse laser to address red dyschromia and discrete telangiectasia, normally confining treatment to the nose, chin, and mid-cheeks with smaller spots (5 to 8 mm). Where there is considerable diffuse redness over the entire face, we use a larger spot size (12 mm) to address the entire region. Using a polarizing light, we examine the vessels closely during irradiation to achieve either stenosis (disappearance) or permanent bluing as endpoints. For larger vessels on the nose or mid-cheek, we normally apply a 3- or even 5-mm spot with a 1064-nm laser with settings ranging from 120 to 130 J/cm² for the 5-mm spot, and approximately 180 to 200 J/cm² for the 3-mm spot, always using the smallest spot that will match the vessel diameter. This approach is typically only effective for vessels larger than 0.6 mm. Smaller vessels are best addressed by a visible light technology like 532 or 595 nm. Even in type IV skin, small vessels can be closed with visible light technologies, so long as adequate cooling is applied. The biggest risk with 1064 nm, although helpful insofar as direct epidermal damage, is the considerable heat generated deeper in the dermis—particularly if one stacks pulses or uses too high a fluence and too large a spot. See Tables 1-3 for typical settings with specific devices.

Figure 2A. Patient prior to treatment.

Figure 2B. Patient 3 days after treatment, showing discrete lesion darkening where Q switch laser was applied and background peeling consistent with 1927 nm laser.

Next, we use a 1927-nm laser with a micro spot size of about 140 to 250 µm and cross-sectional coverage of about 30% to 40%. Raised unpigmented or low contrast lesions are treated either with a very small spot CO₂ laser with spot size 1 to 2 mm in full ablation mode or light hyfrecation. If we treat with an RFMN system, we inject approximately 10 cc of a 0.24% lidocaine tumescent lidocaine solution through five-prong 4-mm needles (Mesoram), into the cheek/jawline region. The RFMN system (49 insulated needles spaced 1 cm in diameter with 1 mm pitch) is deployed with needle depth of roughly 2 to 3 mm along the jawline and cheeks with settings of roughly 5 W and 500 ms (about 2.5 J/pulse or 50 mJ/needle). After treatment, the patient is provided ice packs, and they use a gentle cleanser for 3 to 4 days along with a barrier ointment. Starting 4 to 5 days after the procedure, they can resume sunscreens and some non-irritating rejuvenation products; they can resume all antiaging products in about 3 weeks. Patients normally send photographs through our portal 2 and 6 days after the procedure to ensure normal wound healing.

RESULTS

Representative results are shown in Figure 3. We normally do a second or third treatment with the radiofrequency device at 2-month intervals but otherwise do not perform additional treatments for a year or more. The most common concern patients have after the procedure is persistent pigmented lesions. Patients often refer to these as “missed” lesions, but normally they are just challenging low contrast lesions. We often offer a low-cost over or no-charge touchup treatment 4 to 8 weeks after the initial, more comprehensive treatment.

Figure 3. Patient before and after treatment sequence, showing effect of radiofrequency microneedling and surface treatment with combination of devices.

DISCUSSION

There are many unmet needs in energy-based cosmetic dermatology, such as cellulite, melasma, excess fat, and “loose” extremity skin (crepeness). Certainly, these are viable frontiers to be “conquered,” however, most patients want predictable freshening with a modest amount of downtime, reasonable cost, and a degree of discomfort that can be managed without sedation. The aforementioned recipe meets those needs. Furthermore, the results at the skin surface are readily visible. Although all parts of this procedure set are important, the role of the 1927 fractional laser cannot be understated. If we had to name an MVD (most valuable device), this technology would receive the award. The wavelength is a somewhat magical one, where the absorption coefficient for water is such that typical settings result in very slight disruption of the dermal epidermal junction and preservation of the epidermal barrier function, but still a degree of peeling that patients enjoy and is associated with a good outcome. Although there is some small risk of infection, the advantages of a fractional 1927-nm laser outweigh any short-term concerns. Patients are educated about the rationale for these various device components in the consultation. We use the analogy of the “paint” of the house as being the surface pigment and vascular component, and the so-called “foundation” of the house being addressed by the deeper penetrating radiofrequency microneedling.

CONCLUSION

The group of procedures in this scenario act as sort of a symphony, were each device plays a role in optimizing patient outcomes with minimal visits to the clinic.

1. Mezzana P, Valeriani M. Rejuvenation of the aging face using fractional photothermolysis and intense pulsed light: a new technique. Acta Chir Plast. 2007;49(2):47-50.

2. Weiner SF. Radiofrequency Microneedling: Overview of Technology, Advantages, Differences in Devices, Studies, and Indications. Facial Plast Surg Clin North Am. 2019;27(3):291-303. doi: 10.1016/j.fsc.2019.03.002.

3. Friedman P, et al. Optimizing Outcomes With the 1550/1927 nm Dual Wavelength Non-Ablative Fractional Laser: Experienced User Recommendations. J Drugs Dermatol. 2021;20(11):1150-1157. doi: 10.36849/jdd.6181.

4. Brauer JA, McDaniel DH, Bloom BS, Reddy KK, Bernstein LJ, Geronemus RG. Nonablative 1927 nm fractional resurfacing for the treatment of facial photopigmentation. J Drugs Dermatol. 2014;13(11):1317-22.

5. Hsu SH, Chung HJ, Weiss RA. Histologic Effects of Fractional Laser and Radiofrequency Devices on Hyaluronic Acid Filler. Dermatol Surg. 2019;45(4):552-556. doi: 10.1097/DSS.0000000000001716.

6. Ge S, Chung HJ, Weiss RA. Histologic Effects of Fractional Lasers and Energy-Based Devices on Intradermally Injected Hyaluronic Acid Filler for Improving Skin Smoothness. Lasers Surg Med. 2024. doi: 10.1002/lsm.23863.