Successful treatment of periorbital rhytides with non-ablative technique using a simple radiosurgery device Waewsiri Sappachang, MD Suthep Jerasutus, MD Suphannahong Dermatology Clinic, Bangkok, Thailand Background Skin aging is a complex process influenced by genetic and environmental factors and associated with the changes in both epidermis and dermis that includes dyschromia, rough texture, dryness, telangiectasia, fine and coarse rhytides and facial laxity. Among those lines on the face, periorbital rhytides seem to appear most easily that can be noticed even in the early decades of life and they are frequently the motive for cosmetic consultation. Patients often complain of a fatiqued appearance and have older look from the laxity of their lower eyelids. The etiologies of the aging of the lower eyelid are diverse and include prolapse of the orbital fat, hyperactivity of the orbicularis muscles and excessive skin laxity. Over the last decades several methods have been employed in the treatment of facial rhytides, especially nonablative techniques, have become very popular as an alternative to traditional ablative procedures such as CO 2 laser and Er :YAG laser which accompanies by a down time, unwanted side effects and complications although promising in the good result 1. Nonablative rejuvenation systems which aim to improve aging changes in the skin without the destruction of integrity are divided into optical energies and electrical radiofrequency energies. However,skin around the eyes is crucial to rejuvenate because the skin is thin, frail and limited in area. Moreover, the use of optical energy source from laser or broad band light is difficult because they have the potential to cause eye injury or eyerash burning through short exposure to either the direct or reflected beam. In contrast to these devices, the radiofrequency unit used electricity may be the treatment of choice for nonablative technology to treat rhytides of the eyelids. They have previously reported on the ability to correct skin laxity and obtain cosmetic improvement using a novel radiofrequency medical device ( Therma. Cool Tc, Thermage Inc, Hayward, CA ). Iyer et al 2 reported the good result on 40 patients with rhytides, photodamaged, treated with radiofrequency. Kushikata N. et al 3 studied the clinical effects in skin tightening with radiofrequency in 85 Japanese females and the result showed the relative good improvement at 3 months post treatment. We report here the application of electrosurgical device, (the Ellman Surgitron), with modified ball tip to treat periorbital rhytides and it was found to be simple, safe and effective. 1
Patients and methods 25 Thai females, age ranged from 34-72 years with Fitzpatrick skin type II-V and lower eyelid rhytides and laxity, were enrolled. Exclusion criteria included active skin problems, on going treatment with retinoid or chemical peels, obtaining treatment with laser both ablative and nonablative techniques within 6 months before the study, pregnancy and pace maker or other electro-mechanical implanted. Inform consent was obtained from all patients. Since anesthesia such as pretreatment cooling and topical 5 % lidocaine preparation could raise the cost and complications, the hypoallergic hydroaqua-gel was simply applied on the lower eyelid after removing make up. Then, a one- cmdiameter-ball electrode was applied gently, moving back and forth in circular motion, covered the entire area of lower eyelid. The device released the energy at 2 seconds interval (controlled by foot step or timer) in order to prevent certain area from burning. The electric current was adjusted to cutting and coagulating mode, starting with 25 J/cm 2 and was increased higher as the patients could tolerate. The treatment end point was erythema. All patients underwent side by side, 8 treatment sessions at weekly interval by the same physician. White petrolatum was prescribed to apply on the treated area daily. Photographs were taken before the treatments, at each session, along with monthly follow-up for 3 months and evaluated by 3 unbiased dermatologists. The clinical grading scores were: 3 = excellent improvement 2 = moderate improvement 1 = mild improvement 0 = no improvement Patients also rated their satisfaction. Result All 25 patients had successfully completed the treatment The patients ages ranged from 34-72 years with the mean of 54.4 years. The independent scoring of blinded photographs showed that, all patients displayed gradual improvement throughout the treatment period of observation. After 8 treatment sessions, 6 patients (24%) had excellent improvement (fig. 1,2),13 patients (52%) showed moderate improvement (fig. 3) and 6 patients (24%) had mild improvement. According to the subjective self-evaluation, 12 patients (48 %) were very satisfied, 12 patients (48%) were satisfied with the result and 1 patient (4%) was not satisfied. The monthly follow up evaluation was done for 16 patients. The improvement that was established after the last session for each patient was sustained for 3 months in 10 patients (62.5%)(fig. 4), 2 months in 5 patients (31.25%) and only 1 month in one patient (6.25%) During the treatment, the patients experienced a very warm sensation on the treated site. Mild erythema and mild itching were observed postoperatively but did not last longer than 24 hours and the patients could return to their daily life activities. 2
A B Figure 1. A 44-year- old woman. Pre - (A) and post - (B) treatment showed excellent improvement of fine rhytides. A B Figure 2. A 56- year- old woman. Pre -(A) and post - (B) treatment showed excellent improvement of fine rhytides. 3
A B Figure 3. A 72- year-old woman. Pre -(A) and post - (B) treatment showed moderate improvement of fine rhytides. A B C Figure 4. A 45- year- old woman. Pre- (A) and post- (B) treatment showed excellent improvement of fine rhytides. Follow up at 3 months (C), the effect remained. Discussion There are many treatment modalities currently available for lower eyelid rejuvenation especially radiofrequency which promising the good aesthetic outcome as shown by recent studies. Fitzpatrick R. et al 4 performed a multicenter study of noninvasive radiofrequency for periorbital tissue tightening, 86 subjects with a single treatment (Thermage, Inc.,Hayward CA ) showed Fitzpatrick wrinkle score 4
improvement of at least 1 points in 83.2 %.Unfortunately, there was secondary degree burn of 0.36 % and 3 patients had small area of scarring of a 6 month follow up period. Javier Ruiz- Esparza 5 reported a good cosmetic result using nonablative radiofrequency in nine patients with lower eyelid flaccidity and rhytides. Although the result was gradually observed, patient s satisfaction was remarkable and no complication was encountered. A simple radiosurgery device which has been used for many years in dermatologic surgery, can generate a radiofrequency of 3.8 MHz. Surprisingly, it has never been used for a rejuvenation purpose although it is cheaper and more available compared with other radiofrequency machines. Our study showed that the energy from such a simple device could improve the lower eyelid rhytides in all 25 patients. The exact mechanism of action is unknown but it is hypothesized that radiofrequency technology produces an electric current that delivers an intense, uniform and sustained level of heat through the dermis and subcutaneous tissue, while sparing the epidermis from damage. Heat generated on the treated site induces thermal injury, follow by microscopic wounds and possible immediate collagen contraction 6. As a result of wound healing response, cytokines and growth factors are released to activate fibroblasts and subsequent expression of new and organized collagen synthesis 7. Other mechanism maybe hypothesized that because of the change of collagen s shape by heat leading to a shrinkage and subsequent skin tightening, thus improve the aesthetic appearance. There is a variety of radiofrequency application that has been introduced for facial rejuvenation. However, the optimal treatment parameters remain questionable as well as the ideal energy level for the best result is unknown. The recent study was designed as simple as possible; no anesthesia was used and the energy was adjusted carefully in order to achieve a sufficient heat without being too painful. As a matter of fact that periorbital area is most likely to be the thinness skin, together with a heat reflection effect from the underlying bone to the epidermis, the energy was firstly started at the lowest level of about 25 J/cm 2 and then increased to 95-100 J/cm 2 depending on the patients tolerance. Eric Finzi et al 9 demonstrated the effective result in the treatment of facial and neck laxity using radiofrequency technique. The energy level ranged from 62-91 J/cm 2 which was slightly low, however, with multiple passes, most of 25 patients experienced a moderate improvement. Moreover, with the modified electrode ball of 1 cm. in diameter applying back and forth in circular motion would help to disperse the electricity and prevent the certain area destruction from cutting effect. In our study, 24%, 52% and 24% of 25 patients had excellent, moderate and mild improvement respectively after completed 8 treatment sessions. Anyway, the earliest visible result appeared after 2 treatment sessions while most cases needed 3-4 sessions. The clinical result was gradually improved after the continuity of multiple sessions. Unfortunately, it could not improve in cases of marked laxity. No difference among patients ages related to the degree of clinical outcomes. Besides aging, there are many factors that influence on the severity of periorbital laxity and rhytides, for example, periorbital fat herniation, orbicularis muscle hypertrophy 8 and excessive eyelid skin (or a so-called blepharochalasia) which need 5
to be corrected by surgical procedure. Other causes include the underlying of allergic rhinitis which usually comes along with the itch sensation at periorbital area, inducing the habit of eyelid rubbing. Furthermore, in case of anyone who often cry or sleepless at night, puffy eyelid can occur easily and subsequently cause laxity and rhytides of periorbital skin. The limitation of our study was the total energy applied on the treated site per session was quite low and needed multiple treatment sessions until the clinical improvement could be detected. This suggests that in further study, topical anesthesia should be used so that the higher energy could be directly delivered as well as the number of treatment sessions could be reduced. Anyway, anything other than topical anesthesia is not recommended because when the electro-thermal effect is too high and the patient can not feel or report the pain, the tissue will be severe damaged 10. There were no serious side effects observed in our patients. After the treatment with radiosurgery device, they had only mild erythema or itching sensation on the treated site which mostly resolved within several hours. Conclusion The noninvasive treatment of periorbital rhytides with highfrequency electrosurgery (The Ellman Surgitron) was simple, efficient, and low in cost. All twenty five patients receiving treatment obtained cosmetic improvement without complication or postoperative morbility. It appears to be a safe, effective noninvasive alterative to correct the lower eyelid rhytides. 6
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