Review Article |

Laser treatment for post acne scars A review

Keyal U,1 Huang X,1* Bhatta AK1
Department of Dermatology and Venereology, Tongji Hospital
affiliated to Tongji University School of Medicine, Shanghai, China
1

Abstract
Background: For years, there was no successful treatment for acne scars.
Now, things have changed. With the development of new technologies,
those suffering from acne scarring have multiple options to improve the
tone and texture of the skin. Laser treatments, including ablative and non
ablative laser skin resurfacing are among available treatment options.

*Corresponding Author:

Dr. Huang Xin, PhD, MD

Department of Dermatology and Venereology
Associate Professor
Tongji Hospital affiliated to Tongji University
200065, Shanghai, China
Email: [email protected]

Citation

Keyal U, Huang X, Bhatta AK. Laser treatment for post

acne scars A review. Nepal Journal of Medical Sciences
2013;2(2):165-70.

Methods: The aim of writing this paper is to review information about

acne scarring, as well as potential treatments by laser. The paper will first
concentrate on introduction and classification of acne scarring, then go
on to treatment modalities specifically by laser. This paper will also focus
on post treatment recovery time, side effects and methods to prevent and
treat those side effects.
Conclusion: Ultimate goal of any intervention in acne scarring is not total
cure or perfection; rather it is making scars less visible.
Keywords: Acne scar; laser treatment; post treatment recovery

Introduction:

can be difficult to treat effectively without using treatment

The term scarring refers to a process where collagen

within the skin is damaged from inflammation, leading to
permanent texture changes in the skin. Post acne scars are
the result of compromised collagen production during the

modalities capable of affecting dermal remodeling at least 1

mm below the skin surface.2
Classification of acne scar

natural wound healing process, resulting in topographic

depressions. Additionally, in skin with acne scarring, there
are perpendicular bundles of collagen that anchor the skin of
the scars. Histologically, post acne scars are usually limited to
the epidermis and upper papillary dermis and, thus, amenable
to treatment with a variety of techniques including ablative
and non ablative lasers for skin resurfacing. Resurfacing
procedures for many decades have been considered to
have pre-eminence, but they should not be considered in
isolation, and one needs to combine modalities to maximize
outcomes.1 Given the dermal pathology present with acne
scarring, particularly with atrophic scars, this condition
Page: 165

Figure 1 : Classification of acne scar

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Nepal Journal of Medical Sciences | Review Article

1. Those involving tissue loss (Atrophic scars): Atrophic
scars are broad, shallow, saucer-like indentations that result
from loss of collagen deposition during the wound-healing
process of acne lesions. They are more common than
hypertrophic scars and keloids.

the acne is clear before treating scarring. Many different

treatments, including chemical peels, surgical excision,
punch grafting, dermabrasion, and tissue augmentation
with a variety of dermal fillers, have been used to improve
atrophic acne scars with varying degrees of success.3, 4

1.1. Superficial macular scars: These scars may appear

as macules that may be discoloured, either erythematous if
inflamed and comparatively early or young scars (under 1
year) or with altered pigmentation. Coloring or pigmentation
of scars may be increased in patients with olive-colored
skin and represents mostly a post- inflammatory response
that will fade in 318 months. This requires sun protection.
Reparative treatment may not always be required.

Over the last decade, laser skin treatments for acne scarring
have been primarily centered on laser resurfacing with
carbon dioxide (CO2) and erbium- doped yttrium aluminum
garnet (Er:YAG) lasers. Although these lasers have proven
effective in improving scar appearance through collagen
remodeling and skin recontouring, they have been associated
with extended recovery periods, prolonged erythema, hypo
and hyper pigmentation, and in rare cases, induction of
additional scarring.5,6 As a result of these potential risks
and well-characterized adverse effects of ablative CO2 and
Er:YAG laser resurfacing, non ablative laser technology
using long- pulsed infrared (1,450-nm diode and 1,320-nm
neodymium-doped yttrium aluminum garnet [Nd:YAG])
laser systems were developed as a safe alternative.7

1.2. Deep dermal scarring: Includes icepick scars, rolling

scars and boxcar scars. Ice-pick scars are frequently deeper,
with sharp, steep sides. Rolling scars are caused by damage
under the surface of the skin. They give the skin a wave-like
appearance. They tend to be wide and shallow. Boxcar scars
are angular scars with sharp vertical edges and are often
found on cheeks and temples. They may be shallow or deep.
2. Those involving tissue excess:
2.1. Hypertrophic scars: Confined to the boundary of
the original injury and increase in bulk by pushing out the
margin. They are usually asymptomatic and develop within
weeks after the injury and tend to resolve gradually. They
tend to appear on the upper back, upper chest and deltoid
region but can also appear on mandibular, malar and
glabellar regions.
2.2. Keloids: They are irregularly shaped scars that extend
beyond the borders of the original wound into adjacent
tissue. They are often pruritic and tender. They are common
in mandibular arch, shoulders and sternal region and are
prone to recur.
2.3. Bridge: Bridge is a fibrous string over healthy skin.
They are common on face.
2.4. Papular scars: They are soft elevations, like
anetodermas and are frequently observed on the trunk and
mental area.
Treatment for acne scarring by laser and its side effects
Acne scarring is permanent but can be treated. No treatment
is 100% effective and the best result is improvement, not
perfection. Treatment of scarring may require many different
kinds of treatments, depending on the kind of scarring
present. Treatment of acne scarring can be expensive and
may not be covered by insurance. It is important that all

Figure 2: various options for laser treatment of acne scarring

1. Ablative laser skin resurfacing
1.1. Carbondioxide Laser
Skin resurfacing with the CO2 laser remains the gold standard
technology for production of the most dramatic clinical and
histologic improvement in severely photodamaged and
scarred facial skin.8 producing a wavelength of 10,600 nm,
the CO2 laser penetrates approximately 30 m into the skin by
absorption and vaporization of water-containing tissue. Older
continuous-wave CO2 lasers produced an unacceptable
amount of thermal destruction (up to 200 m2 mm beyond
the target area).9 The new generation of pulsed and scanned
CO2 lasers limit this thermal damage by delivery of high
energy laser light with tissue dwell times shorter than the

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Review Article | Keyal U, et al. Laser treatment for post acne scars
thermal relaxation time of the 30 m of targeted tissue
(about 1 ms). Use of the CO2 laser for skin resurfacing
yields an additional benefit of collagen tightening through
heating of dermal collagen. The triple helical structure of
collagen is altered, resulting in shortening of the fibers by
one third.10 Persistence of this collagen contraction results,
in part, from these shortened fibers serving as a scaffold for
neocollagenesis. Several CO2 laser systems are available
and can be separated into two distinct groups: pulsed and
scanned. CO2 laser has been used effectively to treat atrophic
and other scars.11,12 Sculpting of scars with the laser yields
a more uniform skin texture and stimulates new collagen
formation within the dermal defects. Patients can expect a
mean improvement of 5080% in moderate atrophic scars,
with continued collagen remodeling and scar effacement
for 1218 months postoperatively.11,12 Patients with scars
previously treated with dermabrasion or deep chemical
peels may have additional fibrosis, which is more difficult
to vaporize, thereby reducing their potential outcome. In
addition, these patients also may have concealed hypopigmentation that could become more apparent after laser
skin resurfacing.12,13 Although patients with paler skin
tones are at lower risk for developing postoperative hyperpigmentation, those with darker skin tones can successfully
undergo CO2 laser resurfacing.
1.2. Erbium: Yttrium-Aluminum-Garnet Laser
The emitted wavelength of 2,900 nm is absorbed 1218
times more efficiently by superficial cutaneous tissues, and
approximately 25 m of ablation occurs per pass with
equally narrow zones of thermal necrosis.14 Clinically, this
translates into a shorter postoperative healing time with much
less post treatment erythema and risk of hyper pigmentation
than CO2 lasers. However, immediate collagen contraction is
only about 14%, and long-term collagen remodeling ranges
from 014%.8 Multiple passes with this laser are necessary
to ablate to a similar depth as one pass of the CO2 laser, and
because the Er:YAG effects are photomechanical instead of
photothermal (like the CO2), intraoperative hemostasis is
difficult to achieve.8,15 Therefore, the short-pulsed Er:YAG
laser is limited in its utility for moderate-to-severe acne
scars. Hybrid Er:YAG/CO2 laser systems (e.g., Derma-K,
Lumenis, Santa Clara, CA, USA) are capable of delivering
both CO2 energy for coagulation and Er:YAG energy for
fine tissue ablation. The dual mode Er:YAG (e.g., Contour,
Sciton, Palo Alto, CA, USA) combines short pulses (for
ablation) with longer pulses (for coagulation). The variablepulsed Er:YAG (CO3, Cynosure, Chelms- ford, MA, USA)
system has a range of pulse durations from 500 s to 10
Page: 167

ms, with the longer pulses effecting coagulation and thermal

injury similar to the CO2 laser.16 As a group, these lasers
have been shown to produce deeper tissue vaporization,
greater control of hemostasis, and collagen contraction.
This translates into greater clinical improvement in mildto-moderate acne scars than their short-pulsed predecessors
and thus represent a good compromise between CO2 and
earlier generation Er:YAG laser.17-21
2. Adverse Effects and Complications of ablative LSR
Side effects and complications are varied and greatly
influenced by postoperative care, patient selection, and
operator skill. In general, the side-effect profile after
Er:YAG laser resurfacing is similar but less severe and more
transient when compared with those experienced after CO2
laser resurfacing table 1. 22-24
Table 1: side effects and complications of ablative LSR
Side effects

Mild
complications

Moderate
complications

Severe
complications

Transient
erythema

Prolonged
erythema

Pigmentary change

Hypertrophic
scar

Localized
edema

Milia

Infection (bacterial,
viral, fungal)

Ectropion

Pruritus

Acne

Hypopigmentation

Contact
dermatitis
Postoperative erythema, lasting an average of 4.5 months,
is an expected occurrence in all CO2 laser treated patients
and is a normal consequence of the wound healing process.
Degree of erythema correlates directly with the depth of
ablation and number of laser passes performed.25,26 It may
also be aggravated by underlying rosacea or dermatitis.
Topical agents like retinoic acid derivatives, glycolic acid,
fragrance or chemical containing cosmetics and sunscreens
should be strictly avoided in early postoperative period until
substantial healing has occurred.25 Mild side effects includes
milia formation and acne exacerbation, which may be
caused by the postoperative use of occlusive dressings and
ointments particularly in patients who are acne prone.25-29
Milia and acne usually resolve spontaneously as healing
progresses and application of thick emollient creams and
occlusive ceases. Oral antibiotics may be prescribed for acne
flares that do not respond to topical preparation.25,29,30 Wound
infections associated with ablative laser resurfacing include
staphylococcus and pseudomonas infections and cutaneous

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Nepal Journal of Medical Sciences | Review Article

candidiasis and should be treated aggressively with an
appropriate systemic antibiotic or antifungal agent.31 The
most common infectious complication is a reactivation of
labial HSV infection.25,27 Therefore all patients undergoing
full-face or perioral ablative resurfacing should receive
antiviral prophylaxis even if they report no history of HSV
infection. Patients should begin prophylaxis by the day of
surgery and continue it for 7 to 10 days postoperatively.32
Hyperpigmentation is one of the more common side effects
and occurs to some degree in all patients with darker skin
tones.31,33 The reaction is transient but its resolution can be
hastened with use of topical agents like hydroquinone and
retinoic, azelaic, kojic, and glycolic acid. Hypopigmentation
is particularly intractable to treatment. The use of an
eximer laser or topical photochemotherapy to stimulate
repigmentation has proven successful in some patients.34,35
The most severe complications includes hypertrophic scars
and ectropion formation.33,36 Focal areas of bright erythema
with pruritus, particularly along the mandible, may signal
impending scar formation.32,37 Potent topical corticosteroid
preparations should be applied to decrease inflammatory
response. A pulsed dye laser can also be used to improve
the appearance and symptoms of laser induced burn scars.38
Ectropion of lower eyelid is rarely seen but, if encountered,
usually requires surgical correction.28 In general, lower
fluences and fewer laser passes should be applied in the
periorbital area to decrease the risk of lid eversion.
Side effects and complications after Er:YAG laser
resurfacing are similar to those observed after CO2 laser
skin resurfacing but they differ in duration, incidence, and
severity .39,40
3. Nonablative laser skin resurfacing
While ablative skin resurfacing with CO2 and Er:YAG
lasers has been proven highly efficacious in reversing the
signs of atrophic scars, the associated lifestyle hindrance and
potential complications are often unacceptable to patients.
In recent years, focus has shifted towards nonablative
technologies that deliver either laser, light based, or
radiofrequency energies to the skin.
3.1. Pulsed Dye Laser
Used predominantly for the treatment of hypertrophic
scars.41,42 The most common side effects include mild edema,
purpura, and transient post inflammatory hyperpigmentation.
It has been hypothesized that the selective heating of dermal
vessels leads to release of endothelial-derived growth
factors and cytokines that up-regulate fibroblasts in treated

skin, thereby resulting in neocollagenesis.

3.2. Mid-infrared lasers
Laser systems operating in the mid infrared portion of
the electromagnetic spectrum, including the 1320 nm
Nd:YAG, 1450 nm diode, and 1540 Er:Glass lasers, possess
optimal wave lengths for water-based non-ablative skin remodeling.43 The majority of ultraviolet induced sun damage
occurs at dermal depths of 100400 um and, because the
water absorption coefficient is low at wavelengths longer
than 700 nm, infrared lasers (>1000 nm) are able to better
deliver energy at these tissue depths.44
To protect the epidermis, dynamic cooling is employed. The
hand piece contains a thermal sensor to assist in maintaining
the epidermal temperature below 50C. At 4045C, the
dermis is heated to a temperature reached of 6065.44, 45
The latest generation of the 1320nm Nd:YAG laser (Cool
Touch II, ICN Pharmaceuticals, Costa Mesa, CA) delivers
energies ranging 2838 J/cm2 with a pulse duration of
350 us through a 10 mm spot size hand- piece. Treatments
are usually performed every month for a series of at least
three sessions. Multiple studies have shown efficacy in the
treatment of atrophic facial scars with only mild edema and
erythema post-procedure.45,46 A study comparing the 1320
nm Nd:YAG to the 1450 nm diode laser for treatment of
atrophic acne scars revealed that the 1450 nm laser effected
more significant change in the scar appearance and skin
texture.46 Both mid-infrared lasers, however, induced clinical
improvement. With the additional positive effect of the 1450
nm diode laser on active acneiform lesions,47 this system
may be preferable for those patients with concomitant acne
and atrophic facial scars.
4. Side effects and complications of non ablative lasers.Ablative Lasers/ R
Side effects of non-ablative laser treatments are generally
mild and transient. Local erythema and edema are typically
observed in treated skin; however, a small percentage
of patients in these studies experience superficial burns,
ecchymoses, dysesthesias, and vesiculation.48, 49-52 In some
cases, post treatment hyperpigmentation has been caused by
excessive use of cryogen spray but has resolved with topical
bleaching agents. To avoid reactivation of latent HSV
infections, appropriate oral antiviral prophylaxis should be
considered for all patients regardless of reported HSV status.
Conclusion:
Laser treatment has revolutionized the approach to acne

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Review Article | Keyal U, et al. Laser treatment for post acne scars
scarring but it has yet a long way to go in order to get more
satisfying results in short time. The Results after treatment
will disappoint patients who desire dramatic improvement
in a short period of time. Additionally, although these
technologies have a much lower side effect profile, they
are not devoid of risks. Ultimate goal of any intervention
in acne scarring is not total cure or perfection; rather it is
making scars less visible. Selection of appropriate technique
requires that patient factors as well as the risks and benefits
of the procedure be weighed.
References:
1. Goodman GJ. The limitations of resurfacing techniques
the necessity to combine procedures. Dermatol Surg
1998;24:6878.
2. Jordan R, Cummins C, Burls A. Laser resurfacing of
the skin for the improvement of facial acne scarring:
a systematic review of the evidence. Br J Dermatol
2000;142:41323.
3. Kaplan EN, Falces E, Tolleth H. Clinical utilization of
injectable collagen. Ann Plast Surg 1983;10:43751.
4.

Moritz DL. Surgical correction of acne scars. Dermatol

Nurs 1992;4:2919.

5.

Alster TS. Cutaneous resurfacing with CO2 and

erbium: YAG lasers: preoperative, intraoperative, and
postoperative considerations. Plast Reconstr Surg
1999;103:619-32; discussion 633-4.

6.

Walia S, Alster TS. Prolonged clinical and histologic

effects from CO2 laser resurfacing of atrophic acne
scars. Dermatol Surg 1999;25:92630.

7.

Tanzi EL, Alster TS. Comparison of a 1,450-nm diode

laser and a 1,320-nm Nd:YAG laser in the treatment
of atrophic facial scars: a prospective clinical and
histologic study. Dermatol Surg 2004;30:1527.

8.

Alster TS. Cutaneous resurfacing with CO2 and

Erbium:YAG lasers; preoperative, intraoperative, and
postoperative considerations. Plast Reconstr Surg
1999;103:61932.

9. Lanzafame RJ, Naim JO, Rogers DW, et al. Comparisons

of continuous wave, chop wave, and superpulsed laser
wounds. Lasers Surg Med 1988;8:11924.
10. Ross E, Naseef G, Skrobal M, et al. In vivo dermal
collagen shrinkage and remodeling following CO2
laser resurfacing. Lasers Surg Med 1996;18:38.
11. Walia S, Alster TS. Prolonged clinical and histologic
effects from CO2 laser resurfacing of atrophic acne
Page: 169

scars. Dermatol Surg 1999;25:92630.

12. Alster TS, West TB. Resurfacing of atrophic facial acne
scars with a high energy, pulsed carbon dioxide laser.
Dermatol Surg 1996;22:1514.
13. Alster TS, Lupton JR. Prevention and treatment of
side effects and complications of cutaneous laser
resurfacing. Plast Reconst Surg 2002;109:30816.
14. KaufmannR, Hibst R. Pulsed erbium:YAG laser ablation
in cutaneous surgery. Lasers Surg Med 1996;19:324
30.
15. Walsh JT Jr, Deutsch TF. Er:YAG laser ablation of
tissue: Measurement of ablation rates. Lasers Surg Med
1989; 9:32737.
16. Sapijaszki MJA, Zachary CB. Er:YAG laser skin
resurfacing. Dermatol Clin 2002;20:8796.
17. Tanzi EL, Alster TS. Treatment of atrophic facial acne
scars with a dual mode Er:YAG laser. Dermatol Surg
2002;15:336.
18. Trelles MA, Mordon S, Benitez V, et al. Er:YAG laser
resurfacing using combined ablation and coagulation
modes. Dermatol Surg 2001; 27 :72734.
19. Rostan EF, Fitzpatrick RE, Goldman MP. Laser
resurfacing with a long pulse Erbium : YAG laser
compared to the 950 ms pulsed CO2 laser. Lasers Surg
Med 2001;29:13641.
20. AlsterTS, LuptonJR. Erbium:YAG cutaneous laser
resurfacing. Dermatol Clin 2001;19 :45366.
21. Teikemeier G, Goldberg DJ. Skin resurfacing with the
erbium:YAG laser. Dermatol Surg 1997;23:6857.
22. .Tanzi EL, Alster TS. Single pass carbon dioxide
versus multiple pass Er:YAG laser skin resurfacing : a
comparison of postoperative wound healing and side
effect rates. Dermatol Surg 2003;29:804.
23. TanziEL, AlsterTS. Side effects and complications of
variable-pulsed Erbium : Yttrium-Aluminum-Garnet
laser skin resurfacing: extended experience with 50
patients. Plast Reconstr Surg 2003;111:15249.
24. Nanni CA, Alster TS. Complications of carbon dioxide
laser resurfacing: An evaluation of 500 patients.
DermatolSurg 1998;24:31520.
25. Nanni CA, Alster TS. Complications of carbondioxide
laser resurfacing: an evaluation of 500 patients.
Dermatol Surg 1998;24:315-20.
26. Alster TS. Cutaneous resurfacing with CO2 and
erbium:YAG lasers: preoperative, intraoperative, and

NJMS | Volume 02 | Number 02 | July-December 2013

Nepal Journal of Medical Sciences | Review Article

postoperative considerations. Plast Reconstr Surg
1999;103:619-32.
27. Bernstein LJ, Kauvar AN, Grossman MC, et al. The
short and long term side effects of carbon dioxide laser
resurfacing. Dermatol Surg 1997;23:519-25.
28. Alster TS, Lupton JR. Prevention and treatment of
side effects and complications of cutaneous laser
resurfacing. Plast Reconst Surg 2002;109:308-16.
29. Horton S, Alster TS. Preoperative and postoperative
considerations for cutaneous laser resurfacing. Cutis
1999; 64:399-406.
30. Waldorf HA, Kauvar ANB, Geronemus RG.
Skin resurfacing of fine to deep rhytides using a
charfrecarbon dioxide laser in 47 patients. Dermatol
Surg 1995;21:940-6.
31. Sriprachya-anunt S, Fitzpatrick RE, Goldman MP, et
al. Infections complicating pulsed carbon dioxide laser
resurfacing for photo-aged facial skin. Dermatol Surg
1997;23:527-36.
32. Alster TS, Tanzi EL. Complications in laser and light
surgery. In: Laser Skin Surgery, vol. 2, edited by DB
Goldberg. Philadephia, Elsevier, Inc., 2005, pp. 103118
33. Alster TS. Commentary on: Increased smooth muscle
actin, factor XIII a, and vimentin positive cells in the
papillary dermis of carbon dioxide laser-debrided
porcine skin. Dermatol Surg 1998;24:155.
34. Friedman PM, Geronemus RG. Use of the 308-nm
excimer laser for post resurfacing leukoderma. Arch
Dermatol 2001;137:824-25.
35. Grimes PE, Bhawan J, Kim J, et al. Laser resurfacing
induced hypopigmentation: histologic alteration and
repigmentation with topical photochemotherapy.
Dermatol Surg 2001;27:515-20.
36. Ruback BW, Schroenrock LD. Histological and
clinical evaluation of facial resurfacing using a carbon
dioxide laser with the computer pattern generator. Arch
Otolaryngol Head Neck Surg 1997;123:929-34.
37. Graber EM, Tanzi EL, Alster TS. Side effects and
complications of fractional laser photothermolysis:
experience with 961 treatments. DermatolSurg
2008;4:301-7.
38. Alster TS, Nanni CA. Pulsed dye laser treatment
of hypertrophic burn scars. Plast Reconstr Surg
1998;102:2190-5.

39. Ross VE, Miller C, Meehan K et al. One-pass CO2

versus multiple-pass Er:YAG laser resurfacing in the
treatment of rhytides: a comparison side by side study
of pulsed CO2 and Er:YAG lasers. Dermatol Surg
2001;27:709-15.
40. Zachary CB. Modulating the Er:YAG laser. Lasers Surg
Med 2002;26:223-6.
41. Tanzi EL, Lupton JR, Alster TS. Review of lasers in
dermatology: four decades of progress. J Am Acad
Dermato 2003;l4:131.
42. Lupton JR, Alster TS. Laser scar revision. Dermatol
Clin 2002;20:5565 .
43. Alster TS, Tanzi EL. Benign manifestations of
photodamage: laser and light source treatment. In:
Goldberg DB (ed) Photodamaged Skin. Marcel
DekkerInc, New York, pp 2004; 11543.
44. Hardaway CA, Ross EV. Non-ablative laser skin
remodeling. Dermatol Clin 2002;20:97111.
45. Kelly KM, Nelson JS, Lask GP, et al. Cryogen spray
cooling in combination with nonablative laser treatment
of facial rhy- tides. Arch Dermatol 1999;135:6914.
46. Tanzi EL, Alster TS. Comparison of a 1450 nm diode
laser and a 1320 nm Nd : YAG laser in the treatment
of atrophic facial scars:a prospective clinical and
histologic study. Dermatol Surg 2004;30:1527.
47. Paithankar DY, Ross EV, Saleh BA, et al. Acne
treatment with a 1450 nm wavelength laser and cryogen
spray cooling. Lasers Surg Med 2002;31:10614.
48. Tanzi EL, Alster TS. Treatment of facial rhytides
with a 1450-nm diode laser: A controlled clinical and
histologic study. Dermatol Surg 2003;29:1248.
49. Ruiz Esparza J, Gomez JB. The medical facelift: a
noninvasive, nonsurgical approach to tissue tightening
in facial skin using nonablative radiofrequency.
Dermatol Surg 2003;29:32532.
50. Fitzpatrick R, Geronemus R, Goldberg D, et al. First
multicenter study of noninvasive radiofrequency
for periorbital tissue tightening. Laser Surg Med
2003;33:23242.
51. Hsu TS, Kaminer MS. The use of nonablative
radiofrequency technology to tighten the lower face and
neck. Semin Cutan Med Surg 2003;22:11523.
52. Alster, TS, Tanzi EL. Improvement of neck and cheek
laxity with a nonablative radiofrequency device: a
lifting experience. Dermatol Surg 2004;30:5037.

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