Facial Rejuvenation

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THE PULSED DYE LASER - A NOVEL MODALITY TO TREAT ECCHYMOSES FOLLOWING COSMETIC FACIAL PROCEDURES

Srinivasan Krishna,a,b MD, MPH, Susan E. Sullivan,a RN, CNOR, Edwin F. Williams III,a,b MD, FACS

Williams Center for Excellence, 1072 Troy Schenectady Road, Latham, NY 12110, USA.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Albany Medical Center, 32 Hackett Boulevard, NY 12208, USA.

Corresponding author for proof and reprints:

Edwin F. Williams III, MD, FACS

Director, Williams Center for Excellence

1072 Troy Schenectady Road

Latham, NY 12110, USA.

(518) 786-7000

(518) 786-1160 (fax)

edwilliams@nelasersurg.com (email)

Coauthor address:

Srinivasan Krishna, MD, MPH

Williams Center for Excellence

1072 Troy Schenectady Road

Latham, NY 12110, USA.

(518) 786-7000

(518) 786-1160 (fax)

srinikrishna@yahoo.com

ABSTRACT

Objective:To assess the safety and efficacy of the 595 nm Pulsed Dye Laser (Candela V-Beam) in the treatment of ecchymoses following cosmetic facial procedures.

Methods: 20 consecutive patients with ecchymoses following facial cosmetic procedures were treated with the V-Beam. A 10mm hand piece was used, with settings of 6 ms, 6 J/cm2 and cryogen setting at 30/20. The ecchymotic area was marked out and one half of it was treated on the 5th- 6th post-operative day (POD) and the remaining half was treated on POD 8-10. Three passes were made with each treatment. Clinical photos were obtained pre and post-treatment. Blinded observers evaluated the photos and graded the ecchymoses on a scale of 0-3, with 3 being severe.

Results: The most common procedures associated with ecchymoses were cervicofacial rhytidectomy, facial lipocontouring, thread lift and minimally invasive sub-periosteal midface lift. Treatment with the V-Beam resulted in near complete resolution of ecchymoses within 24-48 hours after treatment. The only side effects were edema and mild discomfort. The maximal efficacy of the laser was observed when the treatment was performed between 6-10 days post-operatively. Patient satisfaction was universally high.

Conclusions: The V-Beam is a safe and effective modality to expedite resolution of post-operative ecchymoses following facial cosmetic procedures. It has wider applications in treating post-operative ecchymoses in other areas of the body and following trauma.

INTRODUCTION

Facial cosmetic procedures are often associated with unsightly post-operative ecchymoses. These can be quite difficult to camouflage with make-up and may be a source of anxiety to our patients. Left untreated, they can last up to 2 weeks and can potentially limit social activities. In our practice, ecchymoses are commonly noted after facial lipocontouring, cervicofacial rhytidectomy, subperiosteal midface lifts, thread lifts and less frequently after filler injections. While efforts to prevent ecchymoses by the perioperative use of such agents as Arnica montana have been somewhat successful [1], there have not been any significant advances in modalities to treat ecchymoses after they have developed.

The Pulsed Dye Laser (PDL) is widely accepted as the treatment of choice for cutaneous vascular lesions [2]. The medical applications of laser technology are based on the principle of selective photothermolysis [3]. This process has three prerequisites: 1. laser wavelength that is preferentially absorbed by the targeted structure or chromophore; 2. an exposure duration less than or equal to the thermal relaxation time of the target tissue and 3. sufficient laser energy per unit area (fluence) to reach damaging temperatures in the target structure, with minimum collateral injury. The principal chromophore for the PDL is hemoglobin in the red blood cells (RBC). Current pulsed dye laser technology achieves selective photothermolysis of RBC with minimal side effects.

Ecchymoses are caused by extravasation of RBC in the soft tissues from surgical trauma and inflammation. We sought to evaluate the safety and efficacy of the pulsed dye laser in targeting these extrvasated RBCs, thereby promoting rapid resolution of ecchymoses.

METHODS

The study was conducted in a private plastic surgical practice setting. 20 consecutive patients who were noted to have ecchymoses following facial cosmetic surgical procedures were enrolled in the study. Informed consent was obtained from all patients for participation in the study. All surgical patients of the practice are routinely instructed to stop taking aspirin or other non steroidal anti-inflammatory drugs (NSAIDS) 2 weeks prior to the procedure. All surgical procedures were performed by the senior author (EFW) in a private surgery center. Standard pressure dressings were used at the end of the procedure. Patients were followed post-operatively, approximately every 48 hours for the first 10 days. All patients were seen on post-operative days (POD) 1 and 3. Subsequent follow-up visits were on POD 5, 6 or 7 and again on POD 8, 9 or 10, depending on the day of the week when the surgery was performed.

On POD 5 or 6, ecchymoses were marked out and the lateral half of the ecchymotic area was treated with the Pulsed Dye Laser (Candela V Beam, Candela Corporation, Wayland, MA). A 10mm spot size was used, with pulse width of 6 ms, fluence of 6 J/cm2 and cryogen setting at 30/20. Three passes were made with the laser. The untreated half of the ecchymotic area served as control. Patients were seen again after 48 hours. The untreated (control) area of ecchymosis was then treated at the same settings and patients returned 48 hours later. Clinical photos were obtained before and 48 hours after each treatment. Three blinded observers evaluated the photos and graded the ecchymoses on a scale of 0-3 (0 - no ecchymosis, 1- minimal, 2 – moderate and 3 – severe). Mean scores were calculated for 'before' and 'after' laser treatment.

RESULTS

All patients completed the study. All patients were Caucasian females, ranging in age from 42-80 years, with Fitzpatrick skin types I-IV, without any significant co-morbidities. None of the patients were taking Aspirin or an NSAID on a regular basis, perioperatively. Procedures commonly associated with post-operative ecchymoses were: facial lipotransfer, cervicofacial rhytidectomy, Contour thread lift and the minimally invasive subperiosteal midface lift. These procedures were performed alone or in combination.

All patients completed the study. All patients were Caucasian females, ranging in age from 42-80 years, with Fitzpatrick skin types I-IV, without any significant co-morbidities. None of the patients were taking Aspirin or an NSAID on a regular basis, perioperatively. Procedures commonly associated with post-operative ecchymoses were: facial lipotransfer, cervicofacial rhytidectomy, Contour thread lift and the minimally invasive subperiosteal midface lift. These procedures were performed alone or in combination.

Treatment with the V Beam resulted in significant improvement or resolution of post-operative ecchymoses within 24-48 hours. M ean ecchymotic scores improved from x (range 2-3) to y (range 0-2). This translated to a … % improvement in the mean ecchymtic score (range …-….%) [table] The maximal efficacy of treatment was observed when the first treatment was performed after POD 5 (POD 6- 10)

Laser treatments were very well tolerated. Untreated areas remained ecchymotic for 4-6 days longer than treated areas. Patients were highly satisfied with the outcome. The only side effects reported were mild discomfort and edema. Dyspigmentation was not observed in any of the patients.

COMMENT

5 consecutive patients with ecchymoses following facial cosmetic procedures were treated with the PDL in an effort to expedite resolution of the bruising. Patients were divided into three groups of 5 each (Groups A, B and C). Initial treatment with the PDL was performed on post-operative day (POD) 3, 6 and 9 on Groups A, B and C respectively. Patients were evaluated and additional treatments were performed as needed in 48 hour intervals until the ecchymoses resolved. Photographs were obtained before and after each treatment. In each group, laser settings used were randomly chosen to be either 10mm x 6 ms x 6J/cm2; 7 mm x 3 ms x 6J/cm2 or 7 mm x 3 ms x 9J/cm2. Photographs were graded by blinded observers on a scale of 1-3 for resolution of ecchymoses.

Results: Treatment was very well tolerated and there were no side effects other than mild discomfort and edema. All three laser settings were efficacious. The settings best tolerated by patients were 10 mm hand piece, 6 J/cm2 fluence and pulse width of 6 ms. Patient satisfaction with treatment was universally high.

REFERENCES

• Seeley BM , Denton AB , Ahn MS , Maas CS. Effect of homeopathic Arnica montana on bruising in face-lifts: results of a randomized, double-blind, placebo-controlled clinical trial. Arch Facial Plast Surg. 2006;8:54-59

 

• Smit JM, Bauland CG, Wijnberg DS, Spauwen PHM. Pulsed Dye Laser treatment, a review of indications and outcome based in published trials. Brit J Plast Surg. 2005;58, 981-987

 

• Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science. 1983 Apr 29;220 (4596):524-7.

 

Table 4: Means by Observer

(Candela V Beam) used in our study is 595 nm which is in close proximity to the second absorption peak of oxyhemoglobin.

We sought to,The wavelength of 6 ms is large enough to achieve the required depth of penetration into the dermis. Conservative fluence of 6 J/cm2 was used. Cryogen spray in used to cool the epidermis skin, immediately preceding the laser treatment. This provides for an analgesic effect, while minimizing thermal injury to the surrounding dermis .

All patients completed study

All patients were female

Patient age range: 42-80

Fitzpatrick skin types I-IV

Procedures commonly associated with post-operative ecchymoses:

facial lipotransfer

cervicofacial rhytidectomy

Contour thread lift

minimally invasive subperiosteal midface lift

Treatment very well tolerated

Side effects: mild discomfort, edema

Patients highly satisfied with outcome

Untreated areas remain ecchymotic for 4-6 days longer than treated areas

(Candela V Beam) used in our study is 595 nm which is in close proximity to the second absorption peak of oxyhemoglobin.

We sought to,The wavelength of 6 ms is large enough to achieve the required depth of penetration into the dermis. Conservative fluence of 6 J/cm2 was used. Cryogen spray in used to cool the epidermis skin, immediately preceding the laser treatment. This provides for an analgesic effect, while minimizing thermal injury to the surrounding dermis .

All patients completed study

All patients were female

Patient age range: 42-80

Fitzpatrick skin types I-IV

Procedures commonly associated with post-operative ecchymoses:

facial lipotransfer

cervicofacial rhytidectomy

Contour thread lift

minimally invasive subperiosteal midface lift

Treatment very well tolerated

Side effects: mild discomfort, edema

Patients highly satisfied with outcome

Untreated areas remain ecchymotic for 4-6 days longer than treated areas