Vol. 32. No. 1


Just a few short years ago, a special edition like this would have been considered science fiction. It is worth taking a moment to think about where we have been, how far we have come, and where we might be heading. Those of us old enough to remember the early collagen and laser days can only marvel at the progress. Back then, to paraphrase the old proverb, everything did look like a nail. Once progress started, it came with a vengeance. Radio frequency, intense pulsed light, fractional lasers, cryolipolysis, ultrasound, microwave, millisecond, microsecond, picosecond, and the list goes on. Acne scars, sweat, fat, red lesions, brown lesions, skin cancers etc; this list continues as well, and new challenges await. The field of noninvasive procedural dermatology is relatively old, dating back to early laser work by such pioneers as Leon Goldman, Richard Fitzpatrick, Rox Anderson, and Kenneth Arndt. However, rapid advances are a testament to several factors, including technology, physician aptitude, consumer demand, and available corporate funding for research and development. In this context, the future may bring challenges. Consumer demand is likely to remain high, the number of physicians with the skill and interest in using technology is expanding, and innovation shows no signs of slowing down. Whether companies will be financially stable enough to continue support of scientific exploration, as well as remain viable through Food and Drug Administration approval, remains to be seen. The development process for technology is expensive, and it is one of the cautionary links in the chain. The other challenge that looms is physician training, and with it brings two concerns. First, for noninvasive procedures to blossom, we must provide training both during and after residency for physicians to become skilled. The second concern is not new, but that does not diminish its importance, that is, ethics. Providers with a variety of motives have shown interest in the field, including those with minimal skills and/or without MD/DO degrees. It is incumbent on us to ensure basic ethical and skill standards are met, not only to safeguard our patients, but also to protect the future and integrity of our specialty. In this issue of Seminars in Cutaneous Medicine and Surgery, innovative therapies for body contouring will be discussed, including low-level laser therapy, cryolipolysis, and highintensity focused ultrasound. Although each technique has demonstrated promising results, a full characterization of the risks and benefits will likely be realized in the coming years as they are further adopted into clinical practice. The field continues to grow in other directions as well. Low-level laser light therapy can also be used to treat a multitude of common medical conditions, including wound healing, viral infections, and acne. Hyperhidrosis, a relatively common condition that can have a drastic impact on a patient’s quality of life, has disappointing responses to some current noninvasive therapies. In this issue, the use of microwave technology in hyperhidrosis will be discussed, giving providers a promising therapy in their armamentarium. Finally, laser and light devices are increasingly being sought after as an alternative to surgical techniques for skin rejuvenation and also tightening. In this issue, novel non-invasive approaches to facial tightening will be discussed, including the use of radio frequency and microfocused ultrasound. While procedural dermatology is still evolving, the robust development of new therapies, and novel applications of existing therapies, continues to push the limits of what can be done non-invasively. As experience with each modality becomes more defined, providers will be able to choose therapies more selectively for each patient. It is, indeed, a bright time for the field of procedural dermatology, with increasing capabilities and rising patient demand helping to ensure the future success of the field.

Body Contouring Using 635-nm Low Level Laser Therapy

Aditya K Gupta, MD, PhD, FRCPC | Jessica Newburger, DO | Mark S Nestor, MD, PhD | Matthew B Zarraga, DO

Noninvasive body contouring has become one of the fastest-growing areas of esthetic
medicine. Many patients appear to prefer nonsurgical less-invasive procedures owing to
the benefits of fewer side effects and shorter recovery times. Increasingly, 635-nm lowlevel
laser therapy (LLLT) has been used in the treatment of a variety of medical conditions
and has been shown to improve wound healing, reduce edema, and relieve acute pain.
Within the past decade, LLLT has also emerged as a new modality for noninvasive body
contouring. Research has shown that LLLT is effective in reducing overall body circumference
measurements of specifically treated regions, including the hips, waist, thighs, and
upper arms, with recent studies demonstrating the long-term effectiveness of results. The
treatment is painless, and there appears to be no adverse events associated with LLLT. The
mechanism of action of LLLT in body contouring is believed to stem from photoactivation
of cytochrome c oxidase within hypertrophic adipocytes, which, in turn, affects intracellular
secondary cascades, resulting in the formation of transitory pores within the adipocytes’
membrane. The secondary cascades involved may include, but are not limited to, activation
of cytosolic lipase and nitric oxide. Newly formed pores release intracellular lipids, which
are further metabolized. Future studies need to fully outline the cellular and systemic
effects of LLLT as well as determine optimal treatment protocols.
Semin Cutan Med Surg 32:35-40 © 2013 Frontline Medical Communications


Low-Level Laser (Light) Therapy (LLLT) in Skin: Stimulating, Healing, Restoring

Asheesh Gupta, PhD | Daniela Vecchio, PhD | Magesh Sadasivam, MTech | Michael R Hamblin, PhD | Nadav Pam, MD | Pinar Avci, MD | Zeev Pam, MD

Low-level laser (light) therapy (LLLT) is a fast-growing technology used to treat a multitude
of conditions that require stimulation of healing, relief of pain and inflammation, and
restoration of function. Although skin is naturally exposed to light more than any other
organ, it still responds well to red and near-infrared wavelengths. The photons are absorbed
by mitochondrial chromophores in skin cells. Consequently, electron transport, adenosine
triphosphate nitric oxide release, blood flow, reactive oxygen species increase, and diverse
signaling pathways are activated. Stem cells can be activated, allowing increased tissue
repair and healing. In dermatology, LLLT has beneficial effects on wrinkles, acne scars,
hypertrophic scars, and healing of burns. LLLT can reduce UV damage both as a treatment
and as a prophylactic measure. In pigmentary disorders such as vitiligo, LLLT can increase
pigmentation by stimulating melanocyte proliferation and reduce depigmentation by inhibiting
autoimmunity. Inflammatory diseases such as psoriasis and acne can also be managed.
The noninvasive nature and almost complete absence of side effects encourage
further testing in dermatology.
Semin Cutan Med Surg 32:41-52 © 2013 Frontline Medical Communications


The New Age of Noninvasive Facial Rejuvenation

Daniel B Eisen, MD | Omar A Ibrahimi, MD, PhD | Rebecca Kleinerman, MD | Suzanne L Kilmer, MD

The techniques of noninvasive facial rejuvenation are forever being redefined and improved.
This article will review historical as well as present approaches to resurfacing, discussing
the nonablative tools that can complement resurfacing procedures. Current thoughts on the
pre- and postoperative care of resurfacing patients are also considered.
Semin Cutan Med Surg 32:53-58 © 2013 Frontline Medical Communications


The Future of Noninvasive Procedural Dermatology

Murad Alam, MD, MSCI

Noninvasive procedural dermatology has evolved rapidly during the past decade. An array
of skin tightening, resurfacing, and fat-reducing energy devices can now be combined with
filler and neurotoxin injectables to reduce the visible signs of aging with minimal downtime
and risk. In the future, such advances will likely continue, although the pace of technological
breakthroughs is difficult to predict. Complex feedback devices, nanotechnology, and
cell-based therapies will eventually begin to fulfill the promise of scar removal, pigmentation
correction, and replacement of aged skin with skin that is new and completely
functional. Dermatologists are well equipped to retain their leadership in noninvasive
esthetic medicine, and they will, to the extent that they continue to pioneer outstanding
therapies that are effective, affordable, and safe.
Semin Cutan Med Surg 32:59-61 © 2013 Frontline Medical Communications