Clinical Roundtable Supplement — Cynosure July 2012
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Physicians Consider RevLite The Gold Standard In Treating Asian Skin
Jeffrey Frentzen, Executive Editor

Of all the world's regions, Asia presents aesthetic physicians with some of the most notable, and at times dramatic, dermatologic challenges. Throughout this region, most patients have Fitzpatrick skin types III-V, which can make treating this population with laser- or light-based devices difficult. However, there are time-tested solutions available to help dermatologists and aesthetic practitioners in Asia manage these hard-to-treat skin types and indications, such as Q-switched lasers.

The RevLite® EO Q-switched Nd:YAG laser from ConBio, A Cynosure Company (Fremont, California, U.S.), is an evolutionary step in the Company's MedLite® series of lasers, which transformed the Asian aesthetic industry 20 years ago. Today, the RevLite is not only a preferred gold standard among Asian physicians for pigmentary issues, it stands apart as a multi-wavelength aesthetic laser that treats a wide-range of indications.

In darker skin types, photodamage usually presents as pigmentary changes, rather than wrinkling. This is in part because these patients have a higher epidermal melanin content, which can predispose them to an increased risk for epidermal and dermal pigmentary disorders. Asian patients are prone to several of these conditions, such as melasma, freckles and lentigines. Other, typical dermal hyperpigmentation disorders include Nevus of Ota and acquired bilateral macules (Hori's Nevus). The RevLite treats these lesions, sun damage, rough or uneven texture, large pores, age spots, and other signs of aging or discoloration that are also widespread among patients in Asia.

Post-inflammatory hyperpigmentation (PIH) is another common problem that can be treated with the RevLite. PIH includes acne, which is prevalent among Asians and can be quite severe, causing dramatic scarring. Other treatment indications include fine, vellus hair removal; improvement of vascular lesions; tattoo removal, which in this region tends to focus on permanent make-up and other cosmetic tattoos; and skin rejuvenation of the face, hands and chest.

Utilizing the same core technology found in the MedLite, the RevLite emits extremely short pulse durations of 5 ns to 20 ns, which induces a PhotoAcoustic effect while reaching very high energies of over 200 megaWatts (mW) per pulse. RevLite's proprietary PhotoAcoustic Technology Pulse® (PTP) setting allows practitioners to harness very narrow pulse widths at peak energy, offering as much as 60% more power and up to 1.6 joules (J). PTP mode enables delivery of high-energy nanosecond pulses into the dermis without producing acoustic damage to the epidermis, thereby delivering optimal results for non-ablative skin rejuvenation.

With a repetition rate of up to 10 Hz and spot sizes up to 8 mm, the RevLite provides very fast treatments. As a frequency-doubled laser (1064 nm and 532 nm), it can offer up to four wavelengths with additional handpieces available at 585 nm and 650 nm. During treatment, it uses a flat top beam profile that nearly eliminates power spikes or hot spots, delivering energy evenly along the surface of the skin. RevLite targets the chromophore with the PhotoAcoustic effect, which vibrates and shatters the pigment, but does not affect the surrounding tissue.

What indications do you treat using the RevLite?

Philip Bekhor, M.D. - The RevLite is one of the most important workhorses in my practice. It is my preferred treatment for solar lentigines and freckles, and the treatment of choice for Hori's Nevus, Nevus of Ota, caféau- lait type lesions, and occasionally Becker's Nevus. I also use it to treat melasma. In addition, it is a highly reliable and safe means for tattoo removal in all skin types.

Philip Bekhor, M.D.
Laser Unit
Department of Dermatology
Royal Childrens Hospital
Melbourne, Australia

Fan Xin, M.D. - I've used ConBio devices for many years, beginning with the MedLite series of lasers. The advantages include energy stability, good clinical curative effects and fewer side effects. I use it to treat pigmentation and skin disease - in particular, melasma, Nevus of Ota, freckles, caféau- lait spots, tattoos, and Riehl's melanosis. There are many people in China suffering from post-inflammatory pigmentation and acne, and I have used ConBio's devices to help them, along with patients who have large pores or rough skin.

Fan Xin, M.D.
Dermatology Department
Beijing Military General Hospital
Beijing, China

S.C. Rajendran, M.D., D.V.D. - I began using ConBio products in 1996, and in 1999 I became the first physician in India to use the MedLite. In India pigmentation is a big problem, rather than anti-aging. People want to look fairer and have clear, rejuvenated skin. We use the RevLite for laser toning, which rejuvenates the skin, but mostly we use it to treat hyperpigmentation or other serious conditions like Nevus of Ota, some traumatic pigmentation cases that may develop, tattoo removal and fine hair removal.

S.C. Rajendran, M.D., D.V.D.
Vydehi Institute of Medical Sciences and Research Centre
Bangalore, India

Atchima Suwanchinda, M.D. - I have been using RevLite for a year-and-a-half but I have used the MedLite C6 and MedLite4 for much longer - around 16 years. I really like the RevLite, because it has higher pulse energy and a larger spot size; therefore I can work faster compared to the other devices. In my practice, melasma is the number one indication, though I also use the RevLite for skin discolorations since abnormal pigmentation is one of the most common problems in my practice. I also use the RevLite to treat Hori's Nevus, solar lentigines, post-inflammatory hyperpigmentation, periorbital darkening, lip darkening and underarm darkening. It is also very useful for skin rejuvenation.

Atchima Suwanchinda, M.D.
Dermatologist and Dermatologic Surgeon
Medisci Biointegrative and Anti-Aging Center
Bangkok, Thailand

Peter Wong, M.D. - The role of RevLite lasers in my practice can be broadly divided into two categories; namely, treatment as a single tool and in combination with other modalities, which may be surgical or non-surgical. The RevLite is a very versatile, multi-purpose device with four wavelengths to choose from, in addition to the PTP mode. I have used it for facial rejuvenation in patients who do not warrant surgery, or are not yet ready for surgical face-lifts. I often use the PTP mode to provide some degree of skin tightening over the forehead region, especially above the lateral aspects of the eyebrows; at the nasolabial and perioral areas; and also in the neck region, particularly, below the jaw and chin.

What cutting edge treatments are you performing with RevLite?

Dr. Bekhor - Currently, I'm performing low intensity treatments for melasma because too much heat can lead to inflammation and irritation. I am also noting an associated photorejuvenation effect from this treatment. Additionally, I am studying the benefits of the R20 protocol for more rapid elimination of tattoos.

Dr. Xin - I use many different settings to treat pigmentation of the skin. One good thing about the system is that I have choices in how aggressively I can treat patients. Many times, physicians will treat a condition too aggressively and introduce hypopigmentation. This is not good and should be avoided. I can modulate the energy, which allows for better, more consistent outcomes. This same approach is very good for acne also.

Dr. Rajendran - I have more and more people asking if we can do something about their wrinkles. So when a patient comes in to get treated for pigmentary problems and asks if there is some way to deal with her wrinkles I can recommend the RevLite for that as well. It treats a large variety of indications, and at varied wavelengths, which itself is cutting edge.

Dr. Suwanchinda - The RevLite provides me with good options to treat more patients who come in presenting severe indications of melasma and other pigmentation. The safety profile and larger spot size help reduce the incidence of epidermal injury, which leads to textural changes in the patient's skin. There is also a decrease in complications.

Dr. Wong - New uses for the RevLite include facial rejuvenation, especially in the reduction of fine wrinkles, age spots, pigmentation and pores. This is a major benefit, because now wrinkle reduction can be achieved using the same machine I already use to treat other skin problems.

How does the RevLite compare with other treatments and modalities?

Dr. Bekhor - I feel the RevLite is the best system for freckles and lentigines. The endpoints are consistent and easy to identify, such that treatment can be delegated to trained nursing staff. Alternative treatments using millisecond pulse, 532 nm systems have a difficult and subtle endpoint not easily delegated to nonphysician operators. The treatment of lentigines in Asian skin has not been a problem with RevLite. Any post-inflammatory pigmentation has been temporary and controlled with creams.

Dr. Xin - I like to call my ConBio lasers my "friendliest lasers." The main reasons for this are energy stability, good curative effects, mild skin reaction and fewer side effects. This laser-based approach can treat a lot of indications, but for treating Asian skin it is extremely reliable.

Dr. Rajendran - I must answer your question with a question: What laser can treat acne scars, remove hair, reduce pigmentation and rejuvenate your skin efficaciously, and with tremendous safety for the patient? RevLite is a multi-application platform. For patients in India, where there is great desire, for cultural reasons, to have fairer skin, we treat pigmentation foremost. You could use a fractional laser to treat acne scars or maybe melasma; or even a dermal roller might work for acne. However, when you want to treat pigmentation the MedLite and the RevLite are the gold standard.

Dr. Suwanchinda - In terms of clinical practice, RevLite can be used to treat a whole range of pigmentation problems, and it is very safe for darker skin tones. In Asian skin, pigmentation is the number one problem as it represents the aging process for people with darker skin types. In terms of cost-effectiveness, it is a worthy machine to invest in. There are no disposables, and maintenance is minimal and easy to do.

Dr. Wong - At 532 nm, I find it very useful for the removal of isolated pigmented epidermal lesions, which literally "peel off" within a matter of days. I find that the RevLite at a 1064 nm wavelength is very effective for the removal of black tattoos, and with its MultiLite Dye Laser Handpieces at 585 nm and 650 nm, multi-colored tattoos can also be removed. Depending on the quantity, depth and dyes used and the number of treatment sessions, the results may vary. RevLite laser treatments are generally safe and fast to administer.

Have you observed any complications with RevLite treatment? If so, how do you treat them?

Dr. Bekhor - Treatment of lentigines and freckles is extremely safe up to skin type III. Skin type IV may be prone to PIH, requiring hydroquinone post-operatively. Early indications suggest that the use of a compression spoon may reduce this risk. With competent use, tattoo treatments should not be associated with complications, although extreme care is advised with flesh tint and white cosmetic pigments, as they may turn black.

Dr. Xin - The major complication is increased pigmentation or hypopigmentation, in addition to possible recurrence of the indication being treated. This is especially problematic in melasma patients.

Dr. Rajendran - Although I rarely come across hypopigmentation, it is the only complication. You need to be very careful to not do any damage. Usually, I start off under treating the patient, and then depending on the response, I reconsider whether I should increase the energy.

Dr. Suwanchinda - It depends on the condition treated and parameter used. With melasma treatment, rebound melasma with hypo- or hyperpigmentation is the most drastic complication after low fluence 1064 nm treatment. Intense pulsed light (IPL), bleaching cream, good sun protection and other types of facial treatments would be the way to treat this, as the skin is very sensitive and melanocytes are vulnerable to any other or further injuries.

Dr. Wong - Permanent hypopigmentation is difficult to treat, and the only thing we can do is to lighten the surrounding skin to make it less obvious. With 532 nm treatments, PIH is also common in darker skin tones but it is only temporary. Additional complications include acne, herpes activation and other infections; scars and textural changes.

Do you combine the RevLite with other treatments or therapies? I f s o, please describe.

Dr. Bekhor - I combine the RevLite with Q-switched ruby lasers in the management of mixed color tattoos (for the green pigment).

Dr. Xin - Frequently, I use a combination of ruby lasers, Alexandrite lasers, and other devices depending on the patient's needs. Combining treatments can be very successful. One must be cautious not to over treat. The laser has very stable power output, which the practitioner needs to understand and apply in such a way as to avoid over treatment or under treatment. The beam quality is the key in terms of consistency and longevity of results.

Dr. Rajendran - I have used fractional laser technology combined with the RevLite. I treat acne scars with the fractional laser and follow-up with the RevLite for melasma. The RevLite can deal with pigmentation and skin rejuvenation. After the patient's skin has become lighter and fine lines have been treated, always follow that with topical applications like those containing vitamin C, and medicated skin creams.

Dr. Suwanchinda - For holistic treatments, combination treatment is the way to go. Most patients come in with more than one problem. One good thing about RevLite is it can be combined with many modalities in the same session. For example, BOTOX and dermal filler injections can be done during the treatment session, and you can use other energy-based devices such as Ultherapy.

For skin rejuvenation, I use many types of treatments. For instance, right after treating pigmentation I perform electroporation with growth factors, along with whitening agents such as Arbutin or Tranexamic acid, together with light-emitting diodes (LED), to help reduce dyspigmentation problems. Melasma treatments are usually treated with biopuncture, which is the injection of biomaterials over the acupuncture points. I also use acupuncture to help balance the internal hormone system.

Dr. Wong - I use the MiXto fractional CO2 laser from Lasering for the nasolabial and marionette region, and around the mouth, while covering the remaining areas of the face with RevLite during the same session. For those who come to me seeking treatments for facial aging, I consider the effects of chronological age and physiological changes, wear and tear from external agents including sun damage, body weight changes and gravity.

The overall effects of these factors may require different modalities of treatments. For example, I can perform a face-lift to "pull up" and tighten the face. While this will reduce the droopiness and folds, the quality of skin will remain, including the wrinkles and pigmentation. This is where RevLite, dermal fillers and other non-surgical treatments can play a role in enhancing the overall result. In this way, a holistic approach to dealing with the multiple problems of an aging face will enhance the final outcome. The use of RevLite (or other follow-up treatments) following surgery has also helped me to build a closer rapport with my patients, and this, I believe, can make my patients happier.

Can you provide tips for achieving the best outcomes?

Dr. Bekhor - For tattoo removal, adjust the power level according to variations in the pigment intensity. Always aim for a mild endpoint. I had a patient where eyeliner was tattooed too deeply resulting in a migration of the pigment under the whole lower eyelid, which gave her the appearance of having smeared eye make-up. The RevLite was able to clear this subcutaneous pigment completely.

Dr. Xin - Treatment options and outcomes differ from patient to patient. First, be careful when you consider the parameters and endpoints of treatment. The main analysis should take into account the age of the patient, skin condition and color, and depth selection parameters.

Dr. Rajendran - I perform a lot of revision work. For example, a physician might use a radiofrequency-based device or a CO2 laser to remove pigmentation, but this only complicates matters and makes it worse for the patient.

Dr. Suwanchinda - The key to success is choosing the right endpoints. Immediate whitening or lightening - but not too much - should be seen. Another important point is the cooling of the skin and the cream used to soothe the skin immediately after the treatment. For Asians, PIH is very common, and rebound hypo- or hyperpigmentation is difficult to treat. Without these complications, RevLite would be very impressive treatment for a recalcitrant condition like melasma.

I do both pre-and post-cooling to make sure that there is no excess heat accumulation. I also use an ointment containing botanic ingredients to help in reducing inflammation and speed healing. Recalcitrant melasma can be treated well with RevLite and it can also be used as a way to prevent recurrence. The interval between treatments is also important. If you treat too frequently this could cause more complications.

Dr. Wong - One thing that has helped with the RevLite is that I photograph my facial rejuvenation patients using the Visia system from Canfield. Results of the skin analysis by this system have helped me to explain the patient's skin conditions and convince them of the need for facial treatments. It also helps to show them the results of laser rejuvenation, and to compare their conditions before and after RevLite treatments. Prior to using the Visia system, I had to assure my patients that the RevLite treatments had been effective.

Is there any other information you would like to share?

Dr. Bekhor - The RevLite has been a welcome addition to my practice, mainly because of its ability to remove tattoos more comprehensively than other devices. It is especially good at removing very stubborn pigments.

Dr. Xin - The key to successful transformations using the laser, or what I like to call "laser beauty," lies in the equipment. It must be of excellent quality - only the best. However, the practitioner must always remember that for any good equipment to work well, it needs a good operator.

Dr. Rajendran - When you apply light or laser energy to Asian skin, you need to be very careful to not do any damage. At times, I begin treatment by using the RevLite on a lower setting than even the Company recommends; then I increase the energy depending on the patient's response. It is most important to remember that hypopigmentation needs to be avoided. In India, if a patient observes hypo- or hyperpigmentation, they will not like the procedure.

Dr. Suwanchinda - For my patients, hypopigmentation has been the biggest complication in treating a variety of skin problems over the years. The RevLite is an important improvement in technology as it reduces the chances for this adverse event in patient outcomes.

Dr. Wong - For Asian patients that have these skin issues, the RevLite provides many outstanding improvements. In my practice, this is particularly true for those with melasma, and also in the reduction or elimination of many pigmentary problems. For physicians, the device is worth the investment because it covers many dermatologic issues. Finally, with a visual aid such as the Visia system, together with the RevLite, patients are not only convinced, but also see the improvement in measurable "charts" and "percentages," rather than purely relying on our subjective impression.

Editor’s Note: In the following clinical roundtable, five aesthetic practitioners in the dermatologic and cosmetic surgery fields from Asia discuss the RevLite system. Participants included Philip Bekhor, M.D., director of the Laser Unit in the Department of Dermatology at Royal Childrens Hospital in Melbourne, Australia; Fan Xin, M.D., director of the Dermatology Department at Beijing Military General Hospital in China; Atchima Suwanchinda, M.D., a dermatologist, dermatologic surgeon and director at the Medisci Biointegrative and Anti-Aging Center in Bangkok, Thailand; S.C. Rajendran, M.D., D.V.D., a dermatologist and professor at the Vydehi Institute of Medical Sciences and Research Centre in Bangalore, India; and Peter Wong, M.D., consultant plastic surgeon at Timberland Medical Centre in Sarawak, Malaysia.