Pham Huu Nghi reviews his experience using both the PICOCARE and LAVIEEN systems in combination
As human beings grow older, there is a growing interest in facial skin concerns. Moreover, repeated sun exposure results in the appearance of photoaged skin, which clinically involves complex alterations of pigmentary change, uneven skin tone and texture, enlarged pores, and a decrease in collagen and elastin fibers, which appear as fine lines. The demand for safe and effective modalities that rejuvenate the photoaged skin while reducing the risk of PIH has risen steadily over the last several decades.
To maximise the rejuvenation effects and removal of pigmentation, it is recommended to combine various modalities to treat entire skin layers, since the photoaging-related changes originate in both epidermal and dermal photo-damage.
Traditional lasers for aesthetic correction of photodamaged skin including the CO2 laser and the Er:YAG laser are used to remove the epidermis and dermis. Due to the high risk of side-effects such as infection, scarring and postinflammatory hypo- or hyper-pigmentation, these lasers are on the decline. For that reason, fractional beam technologies have been developed and combination strategies using multiple lasers have become increasingly popular.
In our clinic, the largest client base is middle-aged patients, who are mainly in their 40s and 50s, followed by an increasing number of patients in their 30s. Recently, we mainly use combination therapy of picosecond 1,064 nm Nd:YAG Laser with MLA fractional handpiece followed immediately by 1,927 nm fractional thulium laser to treat pigmented lesions and skin rejuvenation.
A combination approach
The combination strategies involve the use of two lasers. First, considering deeper penetration depth in the skin, a 1064 nm picosecond Nd:YAG laser (PICOCARE®, WONTECH Co., Ltd) with fractional MLA handpiece is irradiated via a toning technique, called MLA Toning, on the full-face of the patient. PICOCARE’s ultra-short pulse duration, high peak power and the MLA handpiece consisting of multiple microlens array enable laser light to focus at the centre of each fractionated micro-beam and deliver high-power density in tissue leaving the skin surface and basement membrane intact. Localised high power density generate transient damage, such as cavitation bubbles, called laser-induced optical breakdown (LIOB), between the lower epidermis and deeper dermis. After this, new collagen, elastin fibres and mucin are formed through a natural healing response1.
It leads to an improved dermal environment as well as initiates dermal remodeling in the damaged area, which can contribute to overall skin rejuvenation. Furthermore, since the predominant effects are photo-mechanical rather than photo-thermal with picosecond-domain lasers, pigmentation can be more safely fragmented. A total of 2–3 passes of MLA Toning with a low fluence of 0.8 J/cm2 (at 10Hz), and a large spot size of 10 mm is used for the treatment.
After finishing the MLA Toning, a 1927 nm thulium fractional laser (LAVIEEN®, WONTECH Co., Ltd) was used immediately after in the same session. The 1927 nm laser has a high water absorption rate, which results in higher absorption of laser energy from the epidermis up to the papillary dermis (superficial / upper dermis). Consistent with these characteristics, it is generally used for epidermal pigmented lesions and skin rejuvenation.
By delivering fractionated 1927 nm laser beams, microscopic thermal zones (MTZs), which are ablative and/or coagulative areas, were created. After that, microscopic epidermal necrotic debris (MENDs) within the epidermis and basal layer that act as shuttles for the melanin pigmentations and coagulated compartments are formed. Through the transport role of MEND, the micro-crusts including pigmentations and debris are peeled off naturally. As a result, dyspigmentation (such as melasma and solar lentigines) and uneven skin tone can be successfully improved by promoting the turnover cycle.
Unlike other 1927 nm fractional thulium lasers, the biggest advantage of LAVIEEN is the adjustable detailed parameters of power and pulse duration that facilitate step by step adjustments of the degree of ablation from non-ablation to sub-ablation, and ablation2. For a combination approach, the entire face of the patient was meticulously treated with 8–10 mJ/shot at a distance between each beam of 1 mm with only a single pass to produce mild to moderate sub-ablation reactions, since we already treated the deeper dermis with PICOCARE. If the patient expresses intolerable pain, two passes of lower energy can be used to maintain the same efficacy. An air cooling device was used to alleviate patient discomfort during the treatment.
The LAVIEEN procedure minimises damage to the skin surface via a sub-ablative effect by setting the power and pulse duration in detail. It also accelerates than healing and re-epithelisation process over traditional ablative lasers by keeping the un‑damaged normal tissues surrounding the treatment area with fractional beam technology.
After the Lavieen procedure, it is good to apply liposomised ampoule, which contains nano-sized ingredients such as PDRN and EGF on the skin surface. The active ampoule ingredient can be absorbed deep inside the skin through MTZ, which is already formed by the Lavieen treatment. Applying ampoule helps the treated skin become more tightened and rejuvenated. The skin texture of the treated area, superficial pigmentation, and overall skin tone is much improved in 7 days after the treatment. Simultaneously, skin rejuvenation effects occur through epidermal/upper dermal remodeling and increased mucin formation3.
Patients express high satisfaction with only a single combination session, and the procedure is performed every 8–10 weeks dependent on the healing rate of each patient. Combination modality can be performed with less energy than used in a single modality. Since we use mild to moderate energy parameters, patients felt greatly reduced pain and downtime. There are also benefits to reducing risk of side-effects. Although, each modality’s rejuvenation effects were different according to target layer, entire skin layers were treated at once in the combination treatment, and the clinical results are more dramatic than application of either modality alone.
Compared to conventional ablative fractional lasers, which frequently cause secondary infection or severe side-effects via open wounds in hot and humid climate countries like Vietnam, the treated area can be well managed after the treatment because both lasers induce cavitation or sub-ablative damage in the epidermis or/and dermis leaving the skin surface intact. Once combination treatment was started, all patients received instruction on sun avoidance and protection.
Rejuvenation means restoring the look of youth and reverse photoaging skin, such as epidermal pigmentation, uneven skin tone and texture, and pores and fine lines. PICOCARE with MLA handpiece create vacuoles in the epidermis and deep dermis that result in production of new collagen, elastin fibre and mucin in dermis layer. LAVIEEN forms non- to sub-ablative micro-thermal zone up to the papillary dermis that results in removal of epidermal pigmentation and coagulative damage in superficial dermis.
The combination of two complementary techniques, bottom-up (PICOCARE) and top-down (LAVIEEN) action, promotes more synergistic results; not only re-epithelization and rejuvenation effects but also improvement of pigmentation by compensating for different effects in each skin layer than each modality alone.
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- Yim, S., Lee, Y. H., Choi, Y. J., & Kim, W. S. (2019). Split-face comparison of the picosecond 1064-nm Nd: YAG laser using a microlens array and the quasi-long-pulsed 1064-nm Nd: YAG laser for treatment of photoaging facial wrinkles and pores in Asians. Lasers in medical science, 1-8.
- Kwon, I. H., Bae, Y., Yeo, U. C., Lee, J. Y., Kwon, H. H., Choi, Y. H., & Park, G. H. (2018). Histologic analyses on the response of the skin to 1,927-nm fractional thulium fiber laser treatment. Journal of Cosmetic and Laser Therapy, 20(1), 12-16.
- Manstein, D., Herron, G. S., Sink, R. K., Tanner, H., & Anderson, R. R. (2004). Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers in Surgery and Medicine: The Official Journal of the American Society for Laser Medicine and Surgery, 34(5), 426-438.