Bogle2007

Prévia do material em texto

Review
10.1586/17469872.2.4.427 © 2007 Future Drugs Ltd ISSN 1746-9872 427www.future-drugs.com
Minimally invasive techniques for 
improving the appearance of the 
aging face
Melissa A Bogle
The Laser & Cosmetic Surgery 
Center of Houston, 3700 Buffalo 
Speedway, Suite 700, Houston, 
TX 77098, USA
Tel.: +1 713 622 1720
mabogle@hotmail.com
KEYWORDS: 
aging face, botulinum, fillers, 
fractional photothermolysis, laser, 
light, photoaging, radiofrequency, 
rejuvenation, resurfacing
Rejuvenation of the aging face should be approached with a combination of treatments 
designed to confront the four major changes associated with aging, namely relaxing 
dynamic rhytids due to hyperfunctional muscles, restoring 3D volume and diminished 
subcutaneous tissue, redraping redundant skin and recontouring deep structural anatomy, 
and resurfacing photoaged skin. 
Expert Rev. Dermatol. 2(4), 427–435 (2007)
Aging is a fact of life whether we like it or not.
While we all age at different rates, there are
definite characteristic changes that occur with
the passing of time and exposure to the
elements. Across cultures, youthful features
include a high, arched brow; well-defined, full
cheek; sharp jawline and rounded, full lips
with a detailed Cupid’s bow and sharp
demarcation of the lip borders. 
With age, inevitable changes occur in facial
morphology and skin quality, including fat
atrophy, sagging, wrinkles, dyspigmentation,
fine telangiectasias and irregular texture. In
terms of rejuvenation, the aging face must be
thought of differently than the aged face. The
anatomy is different, the motivation of the
patient is different and the techniques used to
improve the skin and repair structural damage
are often different. This review gives an over-
view of the aging face, including why and how
we age and the four Rs of facial rejuvenation:
relax, refill, redrape and resurface.
Background
Both intrinsic and extrinsic aging contribute to
changes in facial appearance [1]. Intrinsic aging
is biologic aging preprogrammed at a cellular
level. Due primarily to hereditary factors,
intrinsic aging is essentially uncontrollable
given our current understanding and ability
(or lack thereof ) to modify cellular events [2,3].
Certain races and hereditary backgrounds tend
to age more slowly than others, by and large
due to genetically based skin coloring and the
protection it affords from UV radiation.
Intrinsic aging is not a homogeneous process
and appears to evolve with periods of accelera-
tion and deceleration at different times in a
person’s life. 
Extrinsic aging is dictated by a person’s
exposure to the elements and lifestyle habits,
making its degree of influence more control-
lable [2]. The main contributors to extrinsic
aging are UV exposure and smoking, although
health habits, such as sleep, diet, muscle
activity and exercise, also play a role [2,4].
Temperature extremes, wind and UV radiation
take a particularly harsh toll on facial skin
because it is almost continuously exposed to
the environment. 
When one examines histologic samples of
sun-damaged skin in contrast to nonsun-
damaged skin, sun-damaged skin reveals a
markedly thickened and disorganized epider-
mis with dyskeratotic changes [1]. Chronic
stimulation of epidermal melanocytes causes
them to become enlarged, more numerous and
found in higher levels of the epidermis. This
appears as dyschromia, focal hyperpigmenta-
tion, lentigines and keratoses. The extrinsically
aged dermal–epidermal junction contains a
stretch of densely packed collagen with little or
no elastic content and a flattening of the rete
ridges, making it fragile and susceptible to
injury from shearing forces [2,5]. Beneath the
dermal–epidermal junction there is a broad
CONTENTS
Background 
Developing a plan 
for rejuvenation 
Relax 
Refill 
Redrape 
Resurface 
Expert commentary 
Five-year view 
Financial disclosure 
Key issues
References 
Affiliation 
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Bogle
428 Expert Rev. Dermatol. 2(4), (2007)
zone containing tangled masses of elastotic material intermixed
among degenerated collagen fibrils. This change, known as
solar elastosis, is responsible for many of the changes in dermal
architecture associated with photoaging, seen as wrinkling and
uneven texture.
Aged skin cells also have a reduction in metabolic activity
and subsequently have a decreased ability to synthesize colla-
gen, poor wound healing and altered biomechanical
function [6]. Skin is less distensible, less resilient and prone to
fine wrinkling, textural abnormalities and laxity [7]. Decreased
collagen and elastic fibers in the dermis with a decreased water
content lead to a thinning of the dermis [8]. In women, skin
thickness reaches a maximum at 35 years of age, and in men, it
reaches a maximum at 45 years of age [20]. Both sexes have a
gradual decline thereafter [9]. Without sun protection, the first
signs of photodamage appear as early as childhood and the early
teens as innocuous appearing lentigines sprinkled over the face
or shoulders. Individuals in their 20s may begin to develop fine
lines that become more noticeable as they approach their 30s.
Fine wrinkling generally appears first in the upper face with
subtle lines over the lateral and inferior periorbital areas. 
Facial expression habits play a role in the development of
early rhytids. Individuals prone to squinting may develop lines
around the lateral periorbital area (crow’s feet) due to the
underlying action of the orbicularis oculi muscle, and lines
around the inferior periorbital area may be accentuated by the
zygomaticus muscle in the cheek. Vertical glabellar lines may
result from contraction of the corrugator supercilii muscles and
transverse rhytids at the nasal root may result from contraction
of the procerus muscle.
As a person enters his or her 30s, horizontal forehead rhytids
develop due to contraction of the frontalis muscle. There is
gradual ptosis of soft tissue in the forehead, leading to descent
of the lateral portion of the eyebrows and increased hooding in
the upper eyelid. The frontalis muscle eventually develops a
perpetually contracted state in an attempt to overcome this
ptosis, leading to deeper, fixed forehead lines [10]. Increased skin
laxity and weakening of the orbital septum appears frequently
in the mid to late 30s, contributing to excess skin of the upper
eyelids and bulging of the intraorbital fat pads of both the
upper and lower eyelids.
Changes in the lower portion of the face first begin to appear
in the late 20s and early 30s. There is a natural groove at the
superior aspect of the nasolabial folds that represents the point
at which the zygomaticus major and risorius muscles inter-
digitate and insert into the dermis [10]. The zygomaticus major
and risorius muscles are two in a group of six muscles, collec-
tively known as the quadratus labii superioris, which control
the upper mouth. The groove that they shape is present even in
very young faces. In the late 20s and early 30s, the groove
begins to elongate and deepen, becoming the first sign of a
nasolabial fold. 
Young faces have a well-defined cheek mass composed prima-
rily of fat within fine facial septae [11]. With age, facia-retaining
ligaments weaken to varying degrees, causing the cheek to
succumb to the effects of gravity. The result of this is that indi-
viduals in their late 40s and older have a paucity of soft tissue in
the infraorbital region and accentuated nasolabial folds due to
an anterior and inferior projection of the cheek mass [12,13]. 
There is a gradual weakening of the superficial muscular
aponeurotic system beginning in the late 30s and early 40s,
causing further ptosis of the lateral and mid-face regions [2].
Along with these changes comes an accumulation of sub-
mandibular and submental fat, sagging of the submandibular
gland and weakening of the platysma muscle, all of which
obscure the smooth contour of a youthful-appearingjaw line
and a sharp cervicomental angle. 
In the aging face, redistribution and loss of subcutaneous fat
is a significant contributor to flat, hollow contours, particularly
in the infraorbital regions, cheeks and around the mouth. Areas
prone to wasting include the buccal fat pads, malar fat pads,
perioral fat, chin, temporal fossa and periorbital area. 
Individuals in their 50s may begin to see bony absorption of
the maxilla and mandible, enlarging the pre-jowl sulcus and
enhancing the appearance of the jowls. Soft tissue changes in
mid-life also contribute to alterations in the appearance of the
nose. The connection between the upper and lower lateral
cartilages and the support mechanisms of the tip and inter-
domal ligaments slowly weaken [14]. The nasal tip rotates down-
ward and the entire nose actually becomes longer [15]. Nasal
changes are often visually accentuated by the vertical
shortening of the maxilla and mandible. 
Also at this time, fine vertical rhytids may become visible
around the lips due to the underlying action of the orbicularis
oris muscle. Smokers and those who purse their lips habitually
can see these changes as early as their mid to late 30s. The aged
upper lip has a tendency to lengthen and descend vertically and
there is a generalized loss of fullness and support throughout
the entire structure. The Cupid’s bow and philtrum flatten with
age and the smooth, rolled ridge of collagen at the vermillion
border becomes nondistinct. In advanced age, exaggeration of
age-related changes occurs.
Developing a plan for rejuvenation
Rejuvenation of the aging face requires four distinct components
termed the four Rs: relax (muscle-related wrinkles), refill (fat
atrophy and volume loss), redrape (sagging and lax skin) and
resurface (texture, color and tone). In the initial consultation it is
important to listen carefully to the patient to discern what is truly
bothersome to them. What the physician sees and what the
patient sees are often not the same issue. If the physician
addresses what he or she perceives to be problematic but does not
address the patient’s primary concern it can lead to
disappointment and misgivings on both sides of the relationship. 
After a picture of the patient’s goals, motivation and lifestyle
is complete, a comprehensive physical examination of the face
should be performed. Careful attention should be paid to the
quality of the skin (texture, rhytids, telangiectasias and dyschro-
mia), muscle- or movement-related furrows, quality and
position of subcutaneous fat and degree of laxity. A well-trained
Minimally invasive techniques for improving the appearance of the aging face
www.future-drugs.com 429
eye will be able to hone in on intricate facial changes associated
with aging and develop a plan for facial rejuvenation that will
give the greatest benefit with the least risk. 
Goals in the management of the aging face include elements
of surface repair, restoration and enhancement. When forming
a framework of therapeutic options, it is easy for a physician to
get into the habit of offering one or two favorite treatments that
may or may not suit all patients equally well. It is essential to
look at each patient individually, including what kind of
upkeep they are willing to tolerate. For example, the first treat-
ment many physicians would consider for improving nasolabial
folds is a soft tissue filler, such as those containing hyaluronic
acid. However, patients have to return for retreatment approxi-
mately every 6 months. For patients unwilling or unable to
tolerate such a schedule it may be a better option to offer a
theoretically longer-lasting filler, such as autologous fat, or to
go another direction entirely, such as infrared or radiofrequency
skin tightening. 
A skilled physician should be able to attack a problem from
many different angles, depending on his or her available
resources and what is the best fit for the individual patient. A
variety of treatments and procedures should be discussed with
the patient, outlining the risks, side effects, costs, invasiveness,
recovery time and anticipated outcomes. 
Relax
Selective chemical denervation of facial musculature is made
possible with the cosmetic use of botulinum toxin. In 1987,
Jean and Alastair Carruthers incidentally noticed the relaxing
effect of botulinum toxin on frown lines in the glabellar region
when they were treating a patient for blepharospasm. Their
results were published in 1992 and the cosmetic use of
botulinum toxin has since become one of the most popular
noninvasive rejuvenation procedures [16]. 
Cosmetic botulinum toxin was originally recommended for
rejuvenation of the upper third of the face. FIGURE 1 shows the
injection sites in a typical patient. The glabellar furrows can be
diminished by injecting the protein into the procerus, corruga-
tor supercili and depressor supercili muscles. Women require
doses of 15–30 units of Botox® (Allergan, CA, USA), whereas
men have been found to benefit from higher doses of 40 units
or greater [17]. Numerous techniques have been described in the
treatment of horizontal forehead rhytids and it is best to indi-
vidualize each session according to the needs of the particular
patient [18]. In general, 12–24 units of Botox are used to treat
the average female forehead, with men requiring slightly more.
Treatment of the lower portion of the forehead carries a greater
risk of brow ptosis, as does unopposed treatment of the fore-
head without concurrent denervation of the glabellar complex.
Trends have shifted toward the use of fewer units in treating the
forehead muscles to avoid an immobile, unnatural appearance.
Studies for the diminution of crow’s feet have found a dose-
dependent relationship between treatment effect and efficacy
up to approximately 12 units per side, making this the most
suitable dosage [19]. Two units of Botox injected 3 mm below
the inferior cilliary margin in the mid-pupillary margin can
improve under-eye rhytids and may also widen the eyelid aper-
ture, giving the eye a more rounded appearance [20]. A lateral
brow lift can be created by injecting two units of Botox into the
orbicularis muscle at the tail of the brow. 
Cosmetic botulinum toxin in the mid and lower portions of
the face has also become increasingly popular. For the upper
nasal sidewall, 2–5 units of Botox can be injected to reduce the
appearance of ‘bunny lines’ on the dorsal nose. In the perioral
area, 2 units of Botox can be injected into the depressor anguli
oris to decrease the ability to frown and raise the position of the
corners of the mouth at rest. This technique is particularly use-
ful in combination with filler substances in the correction of
marionette lines. One to two units of Botox in each quadrant
of the lip softens the appearance of vertical lip rhytids and may
make the lips appear slightly fuller by enhancing eversion [21].
Similarly, 2–8 units injected into the mentalis muscle can
soften textural irregularities in the chin [22].
In addition to Botox, other type A toxins that are available
include Dysport® (Ipsen, Auckland, New Zealand) and
Xeomin® (Merz, Frankfurt am Main, Germany). Dysport is
undergoing multicenter trials for approval in the use of glabel-
lar furrows in the USA where it will be released under the name
Reloxin®. Xeomin is only approved in Germany currently.
Myobloc® (Solstice Neuroscience, CA, USA) is a type B neuro-
toxin known as Neurobloc® in Europe. It is US FDA approved
and used in the USA for neurologic conditions. Some
Figure 1. Injection points on the face illustrating the standard treatment 
sites of botulinum toxin. 
Bogle
430 Expert Rev. Dermatol. 2(4), (2007)
physicians use it off label as an alternative to type A toxins,
however, it has not found widespread cosmetic use and is not
FDA approved for this use.
Refill
Facial fillers can be used to plump up rhytids, scars and defects
due to fat wasting in the aging face. The advent of soft tissue
augmentation dates back to 1883 when Neuberused excised fat
en bloc to reconstruct tuberculosis scars. The modern use of
fillers began in 1982 with the FDA approval of bovine collagen.
Currently, there is an ever-expanding list of available filler
options, including collagen, hyaluronic acid, calcium hydroxy-
lapatite, polymethylmethacrylate, poly-L-lactic acid, silicone
and fat.
There are two broad categories of fillers including micro- and
macrofillers. Which type of filler to use depends on the size and
depth of the defect. Microfillers include products such as colla-
gen and hyaluronic acid, and are best suited for filling fine lines
or localized areas, such as the lips, scars or superficial dermal
folds. Macrofillers, such as fat, are better suited for large
volume correction, such as the cheeks, resculpting the jaw line
and pre-jowl sulcus, or for diffuse facial volume correction.
Either type of filler works well in the nasolabial folds, corners of
the mouth and marionette lines.
Volume restoration is an extremely important concept in
minimally invasive facial restoration. Many patients are not
aware of the lipoatrophy that occurs with aging and are instead
focused on the concept of excess skin. They may think that
they need a face lift, when a face lift would simply pull the skin
taught against bony facial contours, giving a gaunt, skeletal
appearance. The goal in volume restoration is to restore the
rounded contours and convexities of a youthful face. FIGURE 2
illustrates areas commonly needing volume correction in the
aging face. 
Restoration of the aging lips is an art form of its own. The
physician should carefully take note of what changes have taken
place in the patient’s natural contour. Ideally, filler substances
can be used to enhance the fullness of the body of the lip,
paying careful attention to mimic natural contours, such as the
Cupid’s bow, as well as to enhance the vermillion border and
restore a flattened philtrum.
As previously stated, the first FDA-approved filler was bovine
collagen available in three forms: Zyderm I®, Zyderm II® and
Zyplast® (Allergan, Inamed Aesthetics, CA, USA). The down-
side to these fillers was their risk of allergic reaction, require-
ment for pretreatment skin testing and relatively short longev-
ity. The approval of human-derived collagen CosmoDerm®
and CosmoPlast® (Allergan) in 2003 was a major breakthrough
as patients no longer required pretreatment skin testing and
could be treated on the day of consultation. ArteFill® (Artes
Inc., CA, USA) is the first permanent collagen-based filler
recently approved by the FDA in 2006. ArteFill is a biphasic
product combining bovine collagen with a suspension of
polymethylmethacrylate beads [23]. The collagen serves as a
temporary vehicle to introduce the polymethylmethacrylate
beads into the dermis. The polymethylmethacrylate beads grad-
ually become encapsulated in a fibrous network, creating autol-
ogous collagen via fibroplasia. Evolence™ (ColBar LifeScience,
Herzliya, Israel) is a porcine-based collagen structurally similar
to human collagen that does not require skin testing and may
provide a longer-lasting alternative to the presently available
Zyderm and CosmoDerm family of collagens. It is currently
undergoing trials for FDA approval [24].
The hyaluronic acid fillers are the most widely used group of
fillers. Hyaluronic acid is a polysaccharide composed of repeat-
ing units of D-glucaronic acid and N-acetyl-glucosamine. Since
it is not species specific and is found in tissues of all vertebrates,
there is theoretically no need for skin testing for allergenicity.
Molecular weight, particle size and cross-linking vary between
brands and may account for subtle differences in product
behavior and duration. The first hyaluronic acid filler approved
by the FDA was Restylane® (Medicis Aesthetics Inc., AZ, USA)
in 2003. The original site of approval was the nasolabial folds,
however, hyaluronic acid is used routinely in other facial areas,
including the lips, marionette lines, pre-jowl sulcus, tear
trough, upper cheek, glabella, dorsal nose and lateral brow [25].
Hylaform® and Hylaform Plus® (Allergan) derived from
rooster combs, were the next set of fillers to be FDA approved.
Hylaform Plus has a larger median particle size making it better
suited for deep dermal filling. Captique® (Allergan) is very
similar to Restylane in that it is derived from a nonanimal
(bacterial) stabilized hyaluronic acid source. Juvederm™ Ultra
Figure 2. The shaded areas highlight characteristic zones of volume loss 
due to normal aging. 
Minimally invasive techniques for improving the appearance of the aging face
www.future-drugs.com 431
and Ultra Plus (Allergan) were approved in 2006 and contain
the highest concentration of cross-linked hyaluronic acid
currently on the market. This is theoretically supposed to have
some benefits in terms of longevity, however, in clinical practice
the duration appears to be anecdotally similar to the
6–9 months of Restylane.
Calcium hydroxylapatite is a separate type of filler approved
for cosmetic use in facial rhytids and HIV-related lipodystro-
phy in late 2006. Radiesse® (BioForm Medical Inc., CA, USA)
is composed of a 35% concentration of calcium hydroxyl-
apatite microspheres suspended in a cellulose gel. When
injected into the skin, the gel carrier is absorbed after several
months, leaving a scaffold of calcium hydroxylapatite micro-
spheres for fibroblasts to grow on and generate new collagen
[26]. The calcium hydroxylapatite microspheres are gradually
broken down into calcium and phosphate ions. The filler is
reported to last for 1–2 years, although bladder studies in
human subjects have found the presence of calcium
hydroxylapatite after 7 years [27]. 
Sculptra® (Dermik Aesthetics, Sanofi Aventis, NJ, USA) was
originally approved by the FDA in 2004 for the treatment of
HIV lipoatrophy. It is currently awaiting approval for cosmetic
use. Sculptra is a unique filler in that it is a ‘volumizer’ rather
than a direct filler. Composed of polymerized poly-L-lactic
acid, it acts by stimulating fibroblast activity to increase colla-
gen production and thicken the dermis [28]. The product must
be reconstituted at least 4 h in advance with 4–5 ml of
bacteriostatic water and 1–2 ml of lidocaine. Higher dilutions
are recommended for the treatment of thin-skinned areas, such
as the backs of the hands. The product is best injected into the
deep dermis using a fanning or tunneling technique with a
cross-directional pattern to ensure even distribution. After the
liquid carrier is absorbed, phagocytosis of the poly-L-lactic acid
occurs and an inflammatory reaction ensues [29]. This inflam-
matory reaction is thought to be responsible for new collagen
and connective tissue formation. Typically, three to five
injection sessions are needed; however, significant results can be
seen after just two treatments. The duration of effect is
1–2 years or longer.
Autologous fat transfer can provide a safe, relatively long-
term method of volume restoration. In the early 1980s Illouz
and Fournier began to reinject fat removed by liposuction and
syringe aspiration. In the early 1990s Sidney Coleman
described facial recontouring with ‘liposculpture’ and the
present day concept of using fat to reshape the aging face was
born. Longevity rates appear to be highest in areas with the
least movement, such as the cheeks [30]. Survival rates are lowest
in areas with more movement, such as the lips [30]. Objective
evaluation of long-term fat graft survival and results are prob-
lematic. The procedure is highly technique dependent with
layers of ribbon-like fat strands having a greater survival than
large bolus injections [31]. Multiple sessions theoretically result
in longer-term results as a percentage of the injected cells will
survive each treatment. Some physicians prefer to utilize fresh
fat with each session whereas others will use frozen stores from
the initial harvest. Volume enhancement from the injection of
frozen fat stores may actuallybe due to a fibroblastic response
rather than primarily a direct living graft [32].
Redrape
Redraping the aging face has traditionally been left to surgical
means with procedures, such as a brow lift, face lift or blepharo-
plasty. The nonsurgical approach to shaping and lifting sagging
skin and fat is radiofrequency or infrared skin tightening.
While not as dramatic as their surgical counterparts, they are an
attractive option for those who do not wish to go under the
knife. Nonsurgical skin-tightening procedures appear to work
best in the mid-face and along the jaw line but can also be used
on the eyelids, neck and forehead.
The most widely studied unipolar radiofrequency device is
the ThermaCool® device (Thermage Inc., CA, USA). It deliv-
ers uniform volumetric heating at controlled depths to the deep
dermis and subdermal layers of the skin, causing immediate
collagen contraction and subsequent remodeling over the
course of months. This differs from laser and light sources,
which heat tissue targets in accordance with the principles of
selective photothermolysis. It is thought that volumetric heat-
ing causes direct tissue tightening by breaking hydrogen bonds
in the collagen triple helix, causing contraction. Electron
microscopic evaluation of the skin immediately post treatment
supports a morphological change in individual collagen fibrils
with contracted, partially denatured collagen in the mid to
deep dermis. Gradual tissue tightening continues over time as a
result of wound healing. The major limiting factor for universal
acceptance of this technology has been the variability and
unpredictability of results. Low energy, multiple pass treatment
paradigms appear to increase the consistency of results;
however, more work needs to be done [33]. 
The most widely studied bipolar radiofrequency device uses
combined electrical and optical energy with either broadband
light (Aurora, Syneron Medical Ltd, Yokneam, Israel) or a
900-nm diode laser (Polaris, Syneron Medical Ltd). In a bipolar
system, the electrical current passes between two electrodes at a
fixed distance over the skin rather than through a single electrode
with a grounding pad attached to the patient. For skin rejuvena-
tion, the theoretical advantage to this technology is that the radio-
frequency component will penetrate into the skin, potentially
heating deeper tissues than standard nonablative lasers. The laser
component will address superficial lentigines and telangiectasias,
which radiofrequency alone cannot treat. For hair removal and
the treatment of vascular lesions, the goal is to heat the target to a
sufficient temperature that causes permanent injury. The two
forms of energy act synergistically to generate heat at the target, as
structures that have been prewarmed with optical energy have
greater conductivity and greater selective heating by the radiofre-
quency current. Since lower energies of both modalities can be
used to achieve target heating, patient safety is increased and
discomfort is reduced [34]. Other devices (Aluma, Lumenis, Inc.,
CA, USA) have combined bipolar radiofrequency with vacuum
suction in an attempt to advance the technology. 
Bogle
432 Expert Rev. Dermatol. 2(4), (2007)
Resurface
Laser or light therapy, chemical peels and microdermabrasion
can be used to improve the skin’s tone, color and texture. The
goals in rejuvenation of aging skin are threefold: reduction of
vascular anomalies, reduction of pigmentary anomalies and
improvement of static rhytids.
Intense pulsed light is one of the most commonly used
devices for combination therapy. Intense pulsed light sources
use high-intensity flashlamps that emit noncoherent light in a
broad wavelength spectrum from approximately 515 to
1200 nm. The first commercially available device became avail-
able in 1994 (PhotoDerm VL, Lumenis Ltd). Currently, there
is a wide variety of devices available with varying wavelengths,
spot sizes, pulse durations, pulse delays and maximal fluences
allowing for great variability in selecting individual treatment
parameters to suit different skin types and indications. The
most common uses are the treatment of photodamage, benign
vascular conditions, pigmentary disorders, such as lentigines
and hair removal. Fair-skinned patients with a mix of
telangiectasias and patchy, irregular pigmentation are particu-
larly good candidates for intense pulsed light treatments as are
those with poikiloderma of the neck or chest.
The mechanism of action of intense pulsed light systems
follows the principles of selective photothermolysis. This prin-
ciple states that target chromophores in the skin preferentially
absorb certain wavelengths of light. By limiting the exposure of
the light energy to a time shorter than the target’s thermal relax-
ation time, the energy is contained in the selected chromophore
and collateral damage to surrounding tissue is limited. One of
the primary hemoglobin absorption peaks is at 577 nm, while
melanin absorbs light in the range of less than 300–750 nm.
Longer wavelengths penetrate deeper into the skin, so optical
cut-off filters from 515 to 715 nm can be used to eliminate
shorter wavelengths and control the depth of penetration and
target deeper structures, such as hair follicles or blood vessels.
Similarly, cut-off filters can be used to reduce the absorption of
melanin in tanned or dark-skinned patients to avoid erythema,
burns and dyspigmentation. Generally, the 515-, 550-, 560-,
570- and 590-nm filters are used for vascular lesions as inclu-
sion of some of the shorter wavelengths is necessary to ensure
absorption in vessels. The 615-, 645- and 755-nm filters cut-
off more yellow light (577–597 nm) and are commonly used
for hair removal and possibly improvement in superficial
rhytids through fibroblast stimulation and increased collagen
production [35].
Similar to lasers, the pulse duration of intense pulsed light
systems are set to be approximately equal to the thermal relaxa-
tion time of the target structure to appropriately damage the
target without heating the surrounding tissue. The thermal
relaxation time is defined as the time required for the tempera-
ture of a tissue or target to cool as a result of heat conductivity.
Intense pulsed light devices currently on the market have pulse
durations between 0.5 and 88.5 ms. Pulses can be delivered as
single, double or triple pulses, and the time interval between
pulses can be set between 1 and 300 ms. When using high
fluences, it is often a good idea to split the energy into multiple
pulses. The delay between pulses gives the epidermis and
surrounding tissue a chance to cool while keeping heat
confined to the target area. In treating blood vessels, multiple
pulsing may be of benefit as oxygenated hemoglobin is
converted to methemoglobin during the first pulse of the
sequential pulsing. Methemoglobin has a high absorption coef-
ficient throughout the 600–750 nm range where oxyhemo-
globin has a high absorption coefficient up to 630 nm with a
second peak near 900 nm. Larger blood vessels (>0.3 mm in
diameter) require delay times spaced 10 ms or longer to allow
adequate cooling of the epidermis and surrounding structures.
Single pulses and short pulse durations are appropriate for
smaller diameter vessels as heat is assumed to occur instantane-
ously. Darker skinned individuals (types IV–V) should be
treated with caution using the highest available optical filter
(755 nm) and long delay times of 50–100 ms to sufficiently
allow the skin to cool and prevent thermal damage. 
Lasers tailored to target melanin, hemoglobin or water can be
used as monotherapy or in combination to address changes in
the skin associated with photoaging. Prominent telangiectasias
can be treated with visible light lasers, such as the 595-nm
pulsed dye laser or 532-nm potassium–titanyl–phosphate
laser [36]. Lentigines can be treated with lasers that target
melanin, such as the 755-nm alexandrite laser. 
Uneven skin texture, fine rhytids and scarring can be
improved witha myriad of methods for nonablative rejuvena-
tion. Infrared lasers (1064, 1320, 1450 and 1540 nm), low-
energy plasma regeneration, fractional photothermolysis,
visible light lasers (yellow and green), narrow-band light
sources (light-emitting diodes), broadband light sources
(intense pulsed light) and radiofrequency devices can all be
considered [37–39]. Ablative resurfacing is still the gold standard
for the treatment of deep wrinkles and severe solar elastosis.
The CO2 laser has excellent results in terms of heat-induced tis-
sue tightening and improvement of texture, pigment and
rhytids [40]. The short-pulsed erbium:yttrium–aluminum–gar-
net (Er:YAG) laser was developed in the mid-1990s as an alter-
native to the pulsed CO2 laser. The CO2 and Er:YAG lasers are
effective in the treatment of sun-induced wrinkles, brown spots
and skin laxity, but have a disadvantage in that they require a
high level of operator skill to avoid complications, such as
scarring, dyspigmentation and lines of demarcation between
treated and untreated areas. They also require meticulous post-
operative care by the patient and have downtime periods of a
week or more with oozing and denuded skin.
The concept of fractional photothermolysis was introduced
in 2004 in an attempt to deliver results approaching that of
traditional ablative laser resurfacing, without the associated
risks and lengthy recovery period [41]. Whereas traditional laser
resurfacing removes the entire top layer of the skin surface,
creating a visible wound and loss of the skin’s protective func-
tion, fractional laser resurfacing treats a small ‘fraction’ of the
skin at each session. Intact, undamaged skin around each
treated area theoretically acts as a barrier to infection and a
Minimally invasive techniques for improving the appearance of the aging face
www.future-drugs.com 433
reservoir for rapid healing. The first fractional resurfacing laser
developed (Fraxel®, Reliant Technologies Inc., CA, USA) uses a
diode-pumped erbium fiber laser that emits light at a wave-
length of 1540 nm, targeting water in the skin. The beam is
delivered through a microprocessor-controlled hand piece to
produce an array of microscopic thermal zones. Fractional
photothermolysis can be used for the treatment of photo-
damaged skin, facial rhytids, acne scars, surgical scars, melasma
and photodamaged skin [39]. Fractional laser resurfacing has the
advantage of ease of treatment with minimal downtime, and
the disadvantage of requiring multiple treatments for optimal
results. An additional advantage is that it is safe and effective
for the treatment of nonfacial areas, such as the neck, chest and
extremities [39]. 
Numerous other companies have now incorporated the
fractional concept into laser technology. Presently, two different
approaches are being taken. The first approach delivers
columns of laser light to the skin to fractionally heat and irre-
versibly damage the epidermis and high dermis using an
Er:YAG laser delivered through a multilensed hand piece
(1540-nm Fractional Er:YAG, Palomar Medical Technologies
Inc., MA, USA and 1440-nm YAG laser, Affirm, Cynosure
Inc., MA, USA). The second approach uses a fractional infra-
red hand piece to deliver noncoherent light in the
825–1350 nm range as a regular array of small hyperthermic
beams with contact cooling to heat the deep dermis to induce
collagen change and skin tightening (StarLux Fractional IR,
Palomar Medical Technologies, Inc.). Numerous other devices
are in development.
Plasma skin regeneration is a recently developed technology
that uses pulses of ionized inert nitrogen gas to deliver heat
energy directly to the skin. Plasma is the fourth state of matter
in which electrons are stripped from atoms to form an ionized
gas. The plasma is emitted in a millisecond pulse to deliver
energy to the target tissue upon contact without reliance on
skin chromophores. Unlike lasers, there is no reliance on a
specific target, such as water, hemoglobin or pigment. The
nitrogen gas flushes oxygen from the treatment area, so there is
no charring and the skin remains in place to act as a biologic
dressing on the treated area. This simplifies postoperative care
and decreases the risk of adverse effects, such as infection and
scarring. The technology can be used at varying energies for
different depths of effect, from superficial epidermal sloughing
to deeper dermal heating. Indications for plasma skin regenera-
tion include mild-to-severe rhytids, sun-damaged skin, acne
scarring and superficial benign skin lesions. Multiple low-
energy treatments appear to approximate the results of treat-
ments at higher energies, with improvement in dyspigmenta-
tion, texture and fine lines [42]. High-energy treatments may
have better results in terms of skin tightening but will also
increase recovery time by approximately 3–5 days [43].
Light-emitting diodes have also been touted to be of use in a
variety of conditions, including photoaging, acne, rosacea, facial
erythema, skin tone/texture and rhytids. The theory behind the
technology is similar to that of plant cells and photosynthesis.
Low-intensity light photons of the proper parameters interact
with subcellular chromophores to activate cells to induce or
inhibit activity in a nonthermal, nonablative fashion. Blue
(407–420 nm) and red light (633–660 nm) have shown some
efficacy in the treatment of mild-to-moderate inflammatory
acne [44]. Red light at 633 nm is thought to accelerate mast cell
degranulation and increase the synthesis of fibroblast growth
factors [45]. The effects of red light on mast cells may also be of
use for antiaging treatments by increasing fibroblast growth
factors and enhancing angiogenesis. Yellow light (588 nm) is
thought to act in a similar manner in antiaging therapy through
the preferential degranulation of mast cells, release of
glycosaminoglycans, promotion of epithelial remodeling and
stimulation of fibroblasts to produce collagen. Results of a
12-month, multicenter clinical trial of photodamaged facial
skin showed an increase in type I collagen and a decrease in
enzymes leading to collagen breakdown, such as collagenase and
matrix metalloproteins after eight treatments at intervals of
2–5 days. A total of 85% of subjects improved by at least one
grade in the Fitzpatrick scale of periorbital wrinkles [46]. Histo-
logical studies after treatment with pulsed yellow light at
588 nm have documented new collagen formation [47]. 
Expert commentary
Over the last 30 years, there has been an increase in the number of
cosmetic procedures available that help to maintain a youthful
appearance or reverse undesirable changes associated with aging.
This is the result of an aging population with a higher discretion-
ary income, dramatic developments in minimally invasive rejuve-
nation techniques and dissemination of information regarding the
available options. The media has increasingly commented on and
influenced public opinion on cosmetic procedures. Television
make-over shows have popularized new techniques, increased the
public’s understanding of surgical and anatomic principles and
increased patient awareness of available options. Thirty years ago,
patients who desired an improvement in appearance were forced
to undergo conventional surgical procedures with sometimes
lengthy recovery times as their only option. Currently, patients
have access to a variety of noninvasive procedures with zero or
minimal recovery times that can easily be incorporated into their
busy schedules as part of their general upkeep and grooming.
This is true even more so in current society. What motivates
someone to seek out cosmetic procedures varies from person to
person. Motivations may be related to employment and a desire
to feel competitive in their field or they may be more personal,
such as the desire to please a spouse or improve their sense of
well-being. In careers involving intense interpersonal inter-
action, such as sales, politics, business, acting or television, a
person’sappearance is significant. Studies have shown that indi-
viduals perceived as attractive receive preferential treatment in
education, employment, medical care and legal proceedings.
Attractive individuals earn more than those with an average
appearance and individuals with below-average looks garner the
lowest hourly wages. An equally valid motivation is simply a
personal desire to look younger in persons who are aging. 
Bogle
434 Expert Rev. Dermatol. 2(4), (2007)
Rejuvenation of the aging face should be approached with a
combination of treatments designed to confront the four major
changes associated with aging: relaxing dynamic rhytids due to
hyperfunctional muscles, restoring 3D volume and diminished
subcutaneous tissue, redraping redundant skin and recontouring
deep structural anatomy and repairing photo-damaged skin.
Five-year view
The art of cosmetic facial rejuvenation has expanded rapidly
within the last 5 years and can certainly be expected to continue
to do so within the next 5 years. With more choices in the areas
of fillers and botulinum toxins, we may see financial benefits as
companies that offer complimentary products choose to bundle
them for added savings. This will allow the cosmetic market to
continue to expand to encompass consumers who might not
otherwise be able to afford it.
Facial volume enhancement will continue to be a focus with
new fillers coming onto the market. Free fat cell transplantation
is a prospective breakthrough, with some surgeons removing
strips of fat from an area, such as the lower abdomen, and
transferring them into areas that need augmentation. There is
currently no substitute for fatty tissue as silicone and poly-
acrylamides may dislocate in larger volumes and other fillers are
either short-lasting or become too hard in larger volumes. Free
fat cell transplantation may prove to have a higher rate of
long-term survival than standard fat injections.
In the area of lasers and light devices, the next 5 years should
see a continued expansion of fractional devices. Fractional tech-
nology is currently under investigation for use in the delivery of
laser wavelengths targeting pigment and blood vessels in a
concept termed ‘fractional selective photothermolysis’. This
would allow us to deliver energy to a targeted source, such as a
leg vein, in a fractional manner, reducing the overall heat load
to the surrounding tissue and decreasing the risk of untoward
effects. In terms of deep tissue restructuring and skin tighten-
ing, we may see fractional targeting of deep facial structures,
such as the superficial muscular aponeurotic system, with alter-
native forms of focused heating, such as ultrasound, moving us
one step closer to the elusive ‘nonsurgical facelift’.
The next 5 years should also see a focus of laser research on
technologies that selectively target fat. Last year researchers at
the Wellman Center for Photomedicine at Harvard Medical
School (MA, USA) found that at 1210- and 1720-nm laser
light selectively heats fat as opposed to water without
damaging overlying skin. This could potentially be used to
target the sebaceous gland in acne therapy, atherosclerotic
plaques in cardiovascular patients or possibly even in the
treatment of cellulite. 
Finally, the proliferation of spas, salons and walk-in clinics
offering cosmetic procedures performed by nonphysicians will
continue to drive increasing attention to the issue of the
nonphysician practice of medicine. 
Physicians who perform cosmetic procedures should be prop-
erly trained to ensure the highest level of patient care and safety.
Nonphysician personnel performing such procedures should be
appropriately licensed, trained and directly supervised by an
onsite physician as recommended in the position statement of
the American Society of Dermatologic Surgery.
Financial disclosure
The author has no relevant financial interests related to this
manuscript, including employment, consultancies, honoraria,
stock ownership or options, expert testimony, grants or patents
received or pending, or royalties. 
Key issues
• The four Rs of facial rejuvenation are: relax (muscle-related wrinkles), refill (fat atrophy and volume loss), redrape (sagging and lax 
skin) and resurface (texture, color and tone).
• Patients often prefer multiple simple procedures with little or no downtime to fewer larger procedures.
• Avoid using the same treatment options for every patient. Look at each person as an individual with consideration to their goals, 
budget and schedule. What works well for one may not necessarily be ideal for the next. A skilled physician should be able to attack 
a problem from many different angles, depending on his or her available resources. 
• A variety of treatments and procedures should be discussed with the patient, outlining the risks, side effects, costs, invasiveness, 
recovery time and anticipated outcomes. Be straightforward and honest with patients about what to expect in terms of discomfort 
and recovery time. Almost all misunderstandings can be avoided by up-front communication.
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Papers of special note have been highlighted as:
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Affiliation
• Melissa A Bogle, MD
Director, The Laser & Cosmetic Surgery Center 
of Houston, 3700 Buffalo Speedway, Suite 700, 
Houston, TX 77098, USA
Tel.: +1 713 622 1720
mabogle@hotmail.com