Nonablative Dermal Remodeling With a 585-nm,350-lsec, Flashlamp Pulsed Dye Laser: Clinical andUltrastructural AnalysisDAVID GOLDBERG, MD,nw M. TAN, MD,w M. DALE SARRADET, MD,w and MARSHA GORDON

MDw

nSkin Laser and Surgery Specialists of New York and New Jersey, Hackensack, New Jersey, wMount Sinai School ofMedicine, New York, NY

BACKGROUND. A nonablative 350-lsec, 585-nm, flashlamppulsed dye laser is currently being used for the treatment ofrhytides.

OBJECTIVE. To analyze both clinical rhytid improvement andelectron microscopic evidence of ultrastructural changes after

treatment with a nonablative 350-lsec, 585-nm, flashlamppulsed dye laser.

RESULTS. At 6 months after two treatments, 40% of the treated

subjects noted mild improvement in rhytid appearance. Non-

treating physician evaluation revealed some degree of improve-ment in 50% of the treated subjects. Mild improvement inquality and texture of the skin was also reported by 50% of the

subjects. Electron microscopic evaluation showed ultrastructur-al changes that are consistent with new collagen formation.

CONCLUSION. Treatment with a nonablative 350-lsec,

585-nm, flashlamp pulsed dye laser can lead to both clinicaland electron microscopic evidence of improvement inphoto-damaged skin.

THE LASER EMPLOYED IN THIS STUDY WAS TEMPORARILY LOANED BY THE MANUFACTURER.

THE GROWING demand for laser treatment ofage-related rhytides and photo damage, coupledwith high rates of undesirable side effects associatedwith traditional ablative techniques, has led to thedevelopment of new nonablative laser and lightsource technologies.1–13 The nonablative flashlamppulsed dye laser is one of the most recently availablesystems. This laser has been used in Europe fornonablative purposes2 and was Food and DrugAdministration cleared for treatment of periocularrhytides in September of 2000. Pulsed dye lasersselectively target the dermal microvasculature leadingto the release of cytokines, which stimulate fibroblaststo produce new collagen. At lowered deliveredfluences, the light reaching the microvasculature is ofinsufficient intensity to cause vessel rupture orcoagulation; hence, there is no purpura or majorvessel damage. To date, scant information is availablethat analyzes the changes induced by this nonablativepulsed dye laser.

Methods

A total of 10 subjects, with class I–III rhytides, wereenrolled in the study. Six subjects were judged to haveFitzpatrick skin type I, and four had Fitzpatrick skintype II. Twelve anatomic areas were treated. Twosubjects had both periorbital and perioral areastreated. Seven subjects had only periorbital areastreated, and one subject had only the perioral areatreated (Table 1).

The 12 anatomic areas, all showing evidence ofphoto damage, were treated twice at a 1-monthinterval. Laser parameters included a wavelengthof 585 nm, a pulse duration of 350 msec, fluence of2.5 J/cm2, and a 5-mm diameter spot size. (N-lite;ICN Pharmaceuticals, Inc., Costa Mesa, CA). Treat-ment of the entire anatomic region, with one passof adjacent, nonoverlapping pulses, was undertaken soas to avoid clinical purpura. No anesthesia wasrequired.

Clinical photography was undertaken beforeand after the first and second treatment and at 6months after the second treatment. Observed acuteside effects such as erythema, edema, and painwere recorded. Subjects were asked whether theysaw any degree of rhytid improvement at the endof the study. Physician analysis of improvement wasundertaken through photographic evaluation by two

r 2003 by the American Society for Dermatologic Surgery, Inc. � Published by Blackwell Publishing, Inc.ISSN: 1076-0512/02/$15.00/0 � Dermatol Surg 2003;29:161–164

Address correspondence and reprint requests to: David J. Goldberg,

MD, Skin Laser and Surgery Specialists of New York and New Jersey,

20 Prospect Avenue, Suite 702, Hackensack, NJ 07601, or e-mail

westwood@pol.net.

nontreating physicians. Clinical results based oninvestigators’ assessments of photographs wereundertaken using the Fitzpatrick Wrinkle Assess-ment Scale.3 Subjects were also asked whether theynoted any degree of improvement in skin quality andtexture.

Pretreatment and 6-month posttreatment biopsieswere taken and preserved in glutaraldehyde. Tissuespecimens were then analyzed by electron microscopyfor collagen fiber size.

Results

During treatment, minimal discomfort was noted.Immediately after treatment, the majority of subjectsexperienced no clinical signs of skin damage, erythe-ma, or edema. No significant posttreatment pain wasnoted. No subjects reported pigmentary changes,hyperpigmentation or hypopigmentation, erythema,or edema during the course of the study.

Forty percent of the subjects reported at least someperceptible improvement in rhytides 6 months aftertreatment. Slightly greater improvement was notedby the independent physician evaluators. Fiftypercent of the subjects also reported some posttreat-ment improvement in quality and texture of skin.(Figures 1 and 2).

Electron microscopic evaluation of collagen fiberdiameter in pretreatment preauricular skin and adja-cent skin 6 months after the first treatment revealed

both smaller collagen fibers consistent with type IIIcollagen and larger fibers consistent with the forma-tion of mature type I collagen. (Figure 3).

Discussion

Although some improvement was noted in manysubjects, our results are not as dramatic as those seenin a previously reported study.2 The reason for thisdifference is not clear, as our patients were treated atsimilar fluences and presented with similar rhytides. Arecent study also documented nonablative improve-ment following treatment with a 6-ms, 595-nm, pulseddye laser.14 Such variability in nonablative treatmentresults has been previously noted.15

Electron microscopic evaluation of treated skinrevealed findings that are consistent with woundhealing and resultant new collagen formation. Bjerringet al.2 noted an increase in blister fluid type IIIprocollagen after treatment with an identical 350-msec,585-nm, pulsed dye laser. Such findings are consistentwith our findings of electron microscopic evidence oftype III collagen fibers after treatment. It would beexpected that such thin type III fibers would ultimately

Table 1. Wrinkle Classification By Anatomic Site as As-sessed by Investigators

Number

Anatomic Site Class I Class II Class III

Periorbital 4 2 3

Perioral 1 2

Figure 1. Post-treatment assessments.

Figure 2. (A) Before treatment with a 350-msec, 585-nm flashlamppulsed dye laser. (B) Six months after two treatments with a 350-msec,585-nm flashlamp pulsed dye laser.

162 GOLDBERG: NONABLATIVE DERMAL REMODELING Dermatol Surg 29:2:February 2003

be replaced with the thicker type I collagen fibers seenin some of our other treated subjects.

In conclusion, this study demonstrated a mildcosmetic improvement of photo-damaged skin insome patients at 6 months after two treatments witha 350-msec, 585-nm, flashlamp pulsed dye laser. Thiscosmetic improvement of rhytides was achieved with-out the side effects and posttreatment care associatedwith ablative wrinkle-removal procedures. The elec-

tron microscopic findings were consistent with theclinical results. What has yet to be determined iswhether certain subtypes of patients show betterposttreatment clinical improvement than is seen withothers. In addition, future studies using more than twotreatment sessions may lead to better clinical results.

References

1. Zelickson BD, Kilmer SL, Bernstein E, et al. Pulsed dye laser for sundamaged skin. Lasers Surg Med 1999;25:229–36.

2. Bjerring P, Clement M, Heickendorff L, et al. Selective non-ablative wrinkle reduction by laser. J Cutan Laser Ther 2000;2:9–15.

3. Goldberg DJ, Whitworth J. Laser skin resurfacing with theQ-switched Nd: YAG laser. Dermatol Surg 1997;23:903–7.

4. Goldberg DJ, Metzler C. Skin resurfacing utilizing a low-fluenceNd: YAG laser. J Cutan Laser Ther 1999;1:23–7.

5. Goldberg DJ, Samady J. Comparison of intense pulsed light andNd: YAG laser for non-ablative treatment facial rhytids. LasersSurg Med 2001;28:141–4.

6. Goldberg DJ. Non-ablative subsurface remodeling: clinical andhistologic evaluation of a 1320-nm Nd:YAG laser. J Cutan LaserTher 1999;1:153–7.

7. Goldberg DJ. Subdermal resurfacing. Oper Tech Oculoplast OrbitalReconstr Surg 1999;2:188–93.

8. Goldberg DJ. Nonablative resurfacing. Clin Plast Surg 2000;27:287–92.

9. Goldberg DJ. Full-face nonablative dermal remodeling with a 1320nm Nd: YAG laser. Dermatol Surg 2000;26:915–8.

10. Goldberg DJ, Rogachefsky AS, Silapunt S. Non-ablative lasertreatment of facial rhytides: evaluation of a 1450 nm diode laserwith dynamic cooling device. Lasers Surg Med 2002;30:79–81.

11. Fournier N, Dahan S, Barneon G, et al. Non-ablative remodelingwith 1540 nm laser. Dermatol Surg 2001;26:799–806.

12. Goldberg DJ, Cutler KB. Nonablative treatment of rhytids withintense pulsed light. Lasers Surg Med 2000;26:196–9.

13. Alster TS. Improvement of erythematous and hypertrophic scars bythe 585-nm flashlamp-pumped pulsed dye laser. Ann Plast Surg1994;32:186–90.

14. Rostan E, Bowes LE, Iyer S, et al. A double-blind, side-by-sidecomparison study of low fluence long pulse dye laser to coolanttreatment for wrinkling of the cheeks. J Cosmet Laser Ther2001;3:129–34.

15. Goldberg DJ. Non ablative dermal remodeling: does it really work?Arch Dermatol 2002;138:1366–68.

Commentary

This is a small but credible trial of the efficacy of a low-poweredpulsed dye laser for the treatment of facial wrinkles.1 As such, itis significant as a building block in the shaky but growing edifice

of evidence supporting the utility of nonablative resurfacing ingeneral and pulsed dye laser resurfacing2,3 in particular. Thewidespread availability of the pulsed dye laser makes the

strategies presented in this article practically applicable to manyclinical settings.

Methodologically, this study has some strengths. Theconcurrent analysis of before and after photographs by two

blinded physicians constitutes the measurement gold standardfor this type of study, and it was done here. Furthermore, unlikeother studies that lack a biopsy component or limit biopsy

analysis to routine histology, this study included electronmicroscopy of the skin demonstrating change in collagen fibers.

One problem with the method was the absence of controls:

Randomization of subjects to control or treatment groupswould have demonstrated the incremental benefit of thetreatment arm. Another issue that may be addressed in future

studies is the relative wrinkle-reduction efficacy of low-poweredversus high-powered pulsed dye lasers.

When the authors note that ‘‘our results are not asdramatic as those seen in previously reported studies,’’ their

honesty is both startling and refreshing. One of the authorshas been a pioneer in nonablative laser therapy, and it istelling that he is not entirely convinced.4,5 This study also

reminds us how little we understand about the molecularbiology underlying the perceived benefit of nonablativeresurfacing. Finally, if results are variable, are there some

patients with particular anatomic or demographic featureswho are more likely to benefit from treatment? If patientselection can be optimized, the disappointed patient may be

Figure 3. (A) Electron microscopic findings of thin type III collagenfibers. (B) Electron microscopic findings of thicker type I collagen fibers.

Dermatol Surg 29:2:February 2003 GOLDBERG: NONABLATIVE DERMAL REMODELING 163

avoided and the magnitude of the mean benefit increased fortreated patients.

MURAD ALAM, MDChicago, IL

References

1. Goldberg D, Tan M, Sarradet MD, Gordon M. Non-ablative dermalremodeling with a 585 mn, 350 m flashlamp pulsed dye laser: clinicaland ultrastructural analysis. Dermatol Surg, in press.

2. Rostan E, Bowes LE, Iyer S, Fitzpatrick RE. A double-blind side-by-side comparison study of low fluence long pulse dye laser to coolanttreatment for wrinkling of the cheeks. J Cosmet Laser Ther2001;3:129–36.

3. Zelickson BD, Kilmer SL, Bernstein E, et al. Pulsed dye laser therapyfor sun damaged skin. Lasers Surg Med 1999;25:229–36.

4. Goldberg DJ. Non ablative dermal remodeling: does it really work?Arch Dermatol, in press.

5. Leffell DJ. Clinical efficacy of devices for nonablative photorejuve-nation. Arch Dermatol, in press.

164 GOLDBERG: NONABLATIVE DERMAL REMODELING Dermatol Surg 29:2:February 2003