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Editor's Notes

• #2: The described treatments are usually done on the face , but may be applied to any other body area – such as neck, de-colte, hands. In combination, usually all 3 may be performed sequentially in the same session, if skin response allows.
• #5: Epidermal or junctional pigmented lesions are treated by SR/SRA. Deeper dermal pigmented lesions are not indicated (should be treated with Q-switched lasers). Superficial dermal vascular lesions (up to 0.5 mm diameter and depth) are treated by SR/SRA, as the deeper dermal blood vessels can be treated by LV/LVA. Dermal collagen fibers may be treated for wrinkle and scar improvement by both Sublime and Motif IR.
• #7: The simultaneous treatment of browns, reds, and some texture is emphasized. It should be noted that all the treated lesions are superficial: pigmented, vascular and textural. Texture can be improved during treatment as well.
• #8: * 12 mm measured from the center of the RF electrodes
• #9: * 12 mm measured from the center of the RF electrodes
• #10: Following the light absorption, the energy is converted into heat in a photo-thermal reaction and consequently two processes occur: coagulation caused by denaturation of proteins (e.g., cooked eggs) and thermally-induced mechanical damage. Thus, the blood is coagulated by the heat. The endothelial cells in the intima (the inner lining of the vessel) are damaged. There is no perforation – no risk of hemorrhage. Some small blood vessels collapse and disappear (vasoconstriction) instantly, some may be removed in time by phagocytosis, but vessels may reappear if sufficient damage is not done to the walls. Melanin granules coagulate and conducted heat destroys the cells that harbor them.
• #11: Erythema and edema are signs of inflamation associated with cellular damage. It recruits the immune system to eliminate the damaged cells, as well as blood clots or broken melanin particles. The skin around should stay intact and undamaged! Phagocytosis – the process of elimination of small damaged particles and debris “swallowed” by the white blood cells, in particular macrophages, which are recruited from the skin and out of the blood vessels to the damaged tissue area. The clearance process may take up to a few weeks and even months, depending on the lesion size. Large leg veins may take up to 6 month to be cleared away.
• #12: The SRA (vs. SR) is a more aggressive applicator due to the shorter wavelength range and the shorter pulse duration. Therefore it is more suitable for resistant lesions (pigments and fine vessels) on light skin.
• #13: 3 first points of SR – due to milder nature Some fine lines of SR – due to deeper penetration When lesions clear after each sessions, increase the settings gradually.
• #14: Pigmented lesions and fine telangiectasia must be treated in Short pulse type in order to be effective. Deeper vascular lesions may require longer time to heat, so Long pulse is suitable. Larger vessels require lower optical fluence than small ones, as they contain more hemoglobin and absorb better the optical fluence. Dark pigments require lower optical fluence than light ones, as the higher concentration of melanin yields a better absorption of the optical fluence.
• #15: The darker the skin, the lower the optical fluence. As the targets become lighter and less dense in subsequent sessions, it is possible to try and increase the optical energy. Asian patients consider as ST V. If both pigmented and vascular lesions are in the same area – treat the pigments first. Usually, RF is maximal (25 J/cm3) on soft tissue and lower over bone (15 J/cm2) or Sensitive Mode. Generally, pigmented lesions require lower optical fluence than vascular. This is due to the higher absorption coefficient of melanin relatively to hemoglobin, and to the relative low concentration of hemoglobin in the blood, compared to melanin concentration in the lesions. Superficial vascular lesions which are treated with relative high optical fluence may heat up excessively, therefore it is helpful to pre and post cool. This cooling should not be excessive, as it may cause vasoconstriction, and sort cooling (1-2 sec) with the light-guide tip, and not with more drastic cooling, may help.
• #16: Note that the optical energy is ~30% lower than SR, due to the more aggressive nature of SRA. As with SR, the darker the skin, the lower the optical fluence, which is ~30% lower than the SR. Usually, RF is maximal (25 J/cm3) on soft tissue and lower over bone (15 J/cm3) – Sensitive mode. When SRA is applied to darker skin (IV-V), very low optical parameters should be used, and only cautiously by experienced users.
• #18: Treat sporadic lesions anywhere in the trunk and legs, without treating the full area first.
• #19: Vascular lesions darken post treatment due to coagulation by the heat. Erythema/edema are positive signs of immune system recruitment.Vasoconstriction and no blood refilling after pressing the vein and releasing, should be tested after 5-10 minutes. If the blanched vessel reappear or if there is blood refilling, another pass may be attempted. The pigmented lesions will darken after treatment due to aggregation of the smaller broken melanin particles outside the granules and/or the cells. Patients have to be warned that the pigments will look worse than originally for a few days, occasionally 1-2 weeks.The mini crust is a part of the healing process of the heated tissue around the epidermal pigmented lesions. SRA endpoints and eesults vs. SR: More erythema, edema and patient discomfort. Pigmented lesions turn much darker. Some vascular lesions may blanche as immediate treatment endpoint. More swelling when treating severe diffuse vascular target. The patients must be warned that the immediate response will not look good for a few days. In most cases, make-up may be used to cover up the intense response. However, care should be taken when removing the make-up and it should be done very mildly, if at all, to avoid skin irritation.
• #20: General skin response of slight erythema and/or edema is acceptable, but not essential. The textural improvement of the papillary dermis is due to the contracture of the collagen fibers and edema.
• #21: Photos courtesy of Ron Russo, MD, USA. Pigmented and textural improvement.
• #24: Photos Courtesy of Tess Mauricio, MD. Pigmented and textural improvement on dark Asian skin.
• #25: Photos Courtesy of Tess Mauricio, MD.
• #26: Photos Courtesy of Todd Case, MD.
• #32: Wrinkle treatment is based on collagen shrinkage and denaturation all over the dermis – superficial and deep. In order for it to be homogeneous, the heating should not be focused, but rather spread all over. Since water and blood vessels are all over the dermis, they heat up by IR and RF and conduct the heat to the collagen fibers.
• #33: Vector zones should be sized for 10-30 pulses:The areas to be treated should not be too large (>30 pulses) so that the heat will accumulate. At the same time, the area should not be too small (<10 pulses), as heat will accumulate too fast with a burn hazard. Vectors could be marked with a white eyeliner.
• #35: The areas to be treated should not be too large (not over 30 pulses) so that the heat will accumulate. At the same time, the area should not be too small (not under 10 pulses), as heat will accumulate too fast with a burn hazard. Since the Sublime treatment is mild and safe, it is advised to do 50% overlap between pulses.
• #37: Photos courtesy of Mark Meyers, MD, USA.
• #38: Photos courtesy of Ron Russo, MD, USA.
• #46: Photos courtesy of N.S. Sadick, MD, FACP, FAACS and M. A. Trelles, MD, PhD.Published in: Dermatol Surg 31:12 December 2005. Stained histological sections show the spaced and disorganized old collagen fibers of aged skin. Upon elōs treatment, the new collagen fibers appear more compact and organized.
• #51: Final edema may last up to 1-2 days.
• #55: Final edema may last up to 1-2 days.
• #56: Photos courtesy of Shalini Grover, MD.
• #59: Average facial treatment time of ~60 min. If neck is also treated allow additional 15-30 min. Usually, additional facial treatments, such as for acne (AC), for hair removal (DS, DSL) or for deeper veins (LV/LVA), are performed in subsequent sessions, when the protocol for skin rejuvenation and collagen remodeling is terminated.
• #60: SR/SRA are most aggressive to the epidermis, therefore it is best to do them first, when the skin is still not traumatized. When Sublime follows, it will take less passes to reach the endpoint as the skin has already been heated. With excessive photo-damage, doing SR/SRA first, will not enable Sublime in the same session. MxIR may be applied, if it is restricted to the lesions that cover very small areas.
• #61: Photos Courtesy of S. Muholland, MD.
• #62: Photos Courtesy of S. Muholland, MD.
• #63: Photos Courtesy of Vince Afsahi, MD.
• #64: Photos Courtesy of Ron Russo, MD. Notice the nasolabial fold shadows. Also note the neck laxity.
• #65: Photos Courtesy of Ron Russo, MD. Notice the nasolabial fold shadows. Also note the neck laxity.