Using a 1064-nm Picosecond Neodymium-Doped Yttrium Aluminum Garnet Laser for Periorbital Hyperpigmentation

Summary

Here, we present a protocol to describe using a 1064-nm picosecond Neodymium-Doped Yttrium Aluminum Garnet (Nd:YAG) laser with a microlens array for treating periorbital hyperpigmentation.

Abstract

Periorbital hyperpigmentation is a complex condition with multiple underlying causes, such as pigmented, vascular, structural, and mixed factors. The multifaceted nature of the disease presents significant challenges and complexities in its treatment, making it a difficult condition to address effectively. These options include topical cosmetics that can improve the appearance of the affected areas and various chemical treatments. Additionally, fillers are available to enhance volume and smoothen texture, while surgical methods can be employed in more severe cases. Despite these advancements, treating periorbital hyperpigmentation remains challenging. Nowadays, lasers have proven to be highly effective tools in the treatment of a wide range of pigmented diseases. However, there are many types of lasers, and the lack of corresponding guidelines makes the treatment of periorbital hyperpigmentation difficult. Here, we present a protocol describing the use of a 1064-nm picosecond Nd:YAG laser with a microlens array for treating periorbital hyperpigmentation. We discuss optimal energy settings, treatment endpoints, and other side effects while enhancing treatment effectiveness. This approach provides a basis for clinicians to screen and treat patients with eyelids dark circles, ensuring efficacy and safety.

Introduction

Periorbital hyperpigmentation (POH), also known as eye dark circles, is a common cosmetic skin disordercausedby various conditions. Clinically, it presents as symmetric hyperpigmented patches around the eyes distributed on the lower and upper eyelid and may extend to involve the glabella and upper nose¹.Some etiologies that contribute to POH are pigmentation, prominent vasculature, skin laxity, and mixed factors.The dark circle around the eyes causes a tired and old appearance, which becomes a psychological concern for patients, so they seek ways to treat it. The disease is easily diagnosed but refractory to treat. Various equipment and tools have been developed to improve the disorder, liketopical cosmetics, chemical peels,lasers, radiofrequency devices, carboxytherapy, fillers, fat injections, and surgical procedures².

The laser therapy is an effective method for the POH treatment³. Lasers have a selective ability to target endogenous chromophores.The neodymium-doped yttrium aluminum garnet (Nd:YAG) laser is effectively used to treat periorbital dark circles⁴. The ND: YAG laser is known as a selective photothermolysis system. The laser pulse width is extremely short, which can achieve extremely high peak power in an instant, thereby producing a photoacoustic effect on the target color base. The nonlinear absorption energy of the target color base produces a photodecomposition effect, which ultimately produces a blasting phenomenon leading to the formation of cavitation in the epidermis or dermis, in a process known as laser-induced optical breakdown (LIOB)^5,6. There is no damage to the tissues around the LIOB, and the inflammatory reaction is also very slight. With the occurrence of LIOB, new collagen and elastic fibers may appear in the dermis⁷. The 1064-nm picosecond Nd:YAG laser with fractional microlens array offers several advantages, including effective targeting of pigment particles, a short treatment duration, notable results, and minimal adverse reactions. This article outlines the operation and safety precautions associated with the use of the 1064-nm picosecond Nd:YAG laser for treating periorbital hyperpigmentation and presents clinical cases to illustrate the effectiveness of this treatment.

Protocol

All procedures that involve the participation of human subjects strictly adhere to the established ethical standards set forth by the Ethics Committee of The First Affiliated Hospital of Soochow University and follow the Declaration of Helsinki. Image data collection was conducted with patient consent, and routine examination photographs were captured before treatment.

1. Preoperative evaluation

1. Review the patient's medical history.
   NOTE: Patient's medical history, including medication history, allergy history, contraindications to treatment, pigmentary changes, previous cosmetic treatments, and manual surgery.
2. Perform a thorough physical examination. Both the therapist and the patient hold a mirror to examine the area to be treated at the same time.
3. Have the patient sign the informed consent form and take the image data using a digital camera and a skin analysis imaging system.
   NOTE: Photos were taken at 0°, 45°, and 90° angles before and after treatment, and consistent light and position should be selected when taking pictures.

2. Preparation for laser treatment

1. Ask the patient to put on shoe covers when entering the treatment room. Have the patient lie supine to expose the treatment area. Remove jewelry and contact lenses.
2. Use a makeup remover and clean the area with a gentle cleaning product.
3. Shave the hair in the treated area clean to avoid hair burning and competing with melanin for laser energy absorption.
4. Turn on the laser treatment room lights and pre-disinfection of the laser handpiece with 75% alcohol.
5. Take a comfortable position, usually sitting, wash hands, and wear a hat, mask, and gloves.
   NOTE: Patients use out-of-eye goggles. The therapist wore laser safety goggles for the wavelength used.

3. Treatment

1. Choose the Resolve 1064 handpiece (Figure 1A) for the treatment of the patient.
   NOTE: The system delivers a 10 × 10 array of 150 µm-diameter microbeams arranged in a 6 mm × 6 mm square treatment area.
2. Set the energy level between 2.1-2.9 mJ/microbeam, pulse duration of 450 ps, frequency of 5 Hz (Figure 1B).
   NOTE: Patients with Fitzpatrick III or IV typically need treatment energy of 2.1-2.3 mJ.
3. Place the end of the treatment handpiece against the skin, ensuring that the handpiece is perpendicular to the skin.
   NOTE: In the periocular area, the orientation of the laser handpiece should be away from the eyeball to reduce the risk of eye injury.
4. Ensure the pulses overlap by 20% and cover the entire treatment area with laser pulses. Perform the treatment from the side to the middle of the face.
5. Aim for the ideal endpoint of treatment, which is the mild darkening of the lesion with slight exudation and bleeding.
   NOTE: A 1064 nm picosecond Nd:YAG laser with a mean fluence of 2.1-2.9 J/cm² was used at 1 month intervals. Treating once a month for a total of 3 treatments.

4. Postoperative care

1. Apply an ice pack for 15-20 min after treatment and apply a medium-acting corticosteroid cream twice a day for 3 days.
2. Use soothing and moisturizing products for 2 weeks after surgery and avoid harsh skin care products.
3. Avoid sun exposure for 4 weeks after treatment to reduce risks such as postinflammatory hyperpigmentation (PIH). Use a broad-spectrum sunscreen with SPF30+ every day, and use umbrellas, hats, goggles, etc.

Results

We evaluated 20 patients aged 21 to 44 years old(8 females and 12 males, mean age 32.4 ± 6.05 years). A total of 4 patients were classified as having Fitzpatrick skin type III, and 16 patients were classified as having Fitzpatrick skin type IV. A total of 7 patients had a family history of POH, and 13 patients had no family history of POH (Table 1).

All patients received three consecutive treatment sessions using a 1064-nm picosecond laser with a microlens array at 1-mont...

Discussion

POH manifested as brown or dark brown pigmentation spots in the bilateral periocular area. There are different causes of periorbital hyperpigmentation, such as genetics, gender, age, physical conditions, anatomical differences, excessive blood vessels, etc. It is a concern at any age because it can make a person look sad, old, or tired and weaken their sense of well-being and self-esteem. The therapeutic approach must vary depending on the cause, as POH is caused by a variety of factors. For POH due to melanin, there are...

Materials

Name	Company	Catalog Number	Comments
1064-nm Nd:YAG picosecond laser	Syneron-Candela, Wayland, MA, USA	Resolve 1064 handpiece	1064-nm Nd:YAG picosecond laser with fractional microlens array