Sponsored by Fotona
Adrian Gaspar, MD OB/GYN Specialist Owner and Director Espacio Gaspar Clinic of Gynecology Mendoza, Argentina
According to experts, the StarWalker® laser system from Fotona (based in the U.S. and Europe) is the highest energy Q-switched laser on the aesthetic market today. Its unique combination of both pico- and nanosecond pulse durations, along with its proprietary Adaptive Structured Pulse (ASP) technology, allows for an unprecedented range of effective treatment options in one compact system.
Fotona’s unique laser engineering of four complementary wavelengths and 14 laser modalities is harnessed to handle a variety of indications such as pigmented and vascular lesions, acne and acne scar revision, hair reduction and tattoo removal, among others. This versatility provides physicians with a well-rounded option for the treatment of melasma, which is notoriously difficult to manage.
The challenge to treating melasma is the multifactorial nature of the condition. Aesthetic physician and OB/GYN specialist, Adrian Gaspar, MD, is owner and director of the Espacio Gaspar Clinic of Gynecology, Anti-Aging and Bioregenerative Medicine, as well as former professor of gynecology at Mendoza University (Mendoza, Argentina). In his experience, “the advanced nature of the StarWalker platform makes it more than capable of addressing the complex pathology of melasma. It is a nano/pico hybrid system incorporating FRAC3 mode, a uniquely engineered microsecond pulse, and VERSA mode, a millisecond pulse, as well as others that you will need to effectively treat the condition.
“In the 60-year history of melasma treatment, we have learned that the pigment is a protective response by melanocytes to a local inflammatory reaction induced by light,” Dr. Gaspar continued. “Using the variety of modes, pulse durations and wavelengths available in the StarWalker platform, we not only deal with the pigment, as other treatments do, we can mitigate the inflammatory response which causes recurrence and treatment failure.”
The origin of melasma lies in the interaction between pigmentary signs, combined with vascular complications, and reinforced by inflammatory and photo-aging processes, a veritable puzzle to solve. “When the fibroblast, which is the main protagonist, cannot replace the collagen as quickly as it is degrading it leads to a progressive deterioration of the papillary dermis with an increase in free radicals,” explained Dr. Gaspar. “This is followed by local activation of metalloproteinases and release of inflammatory cytokines. The only way the skin can protect itself from the light causing this cascade is the formation of the pigmentary lesions characteristic of melasma. By treating all these factors we obtain superior results to those seen so far in the medical literature.”
According to Dr. Gaspar, the four-step protocol for the treatment of melasma using the StarWalker platform was pioneered by Sebastian Velez, MD and Julio Velez, MD of Colombia. “It perfectly adapts to the current needs of patients with melasma, without recurrence of the condition for at least one year after completion of six treatment sessions. Each of the four steps has a specific objective,” Dr. Gaspar expressed.
After application of topical anesthetic, the first step is four to six passes using MaQX, a pico/Q-switched hybrid mode at a 5 ns pulse duration with the R28D handpiece, spot size 6 to 8 mm, fluence 1 to 2 J/cm2. “This eliminates the melanin in the dermis and disrupts the melanosomes within melanocytes to promote dendridectomy, a term describing the disabling of the production of melanin,” he explained.
The second step harnesses the power of the Nd:YAG wavelength in FRAC3 mode, four passes with pulse duration between 0.3 and 0.6 ms using the same handpiece with a 4 mm spot, fluence between 10 to 20 J/cm2. “The purpose of this,” Dr. Gaspar said, “is to modulate the inflammation that we know is the key point in the genesis and perpetuation of the pigmentary lesion, stopping the stimulus that causes the melanocytes to produce melanin.”
Using the FS20AD fractional ablative handpiece with the Nd:YAG laser to produce an array of 81 250-micron wounds in a 9 mm spot, the third step calls for three to four passes with a 5 ns pulse at 7 to 40 mJ/ms. “This ablative fractional use of the Nd:YAG laser has a strong interaction in the dermis, where the objective is to cause regenerative stimulation of the skin,” Dr. Gaspar began. “We must promote collagen remodeling, mostly in the papillary dermis where the majority of the problem exists, via fibroblast stimulation with cell migration for repair and recovery of dermal hemostasis. This rejuvenates skin quality to rebuild its natural protection from the light that induces the inflammatory response initially.”
The purpose of the fourth and final step is to treat local vascularization. “Dealing successfully with this vascular component is critical to the management of the chronic inflammatory process associated with melasma,” he expressed. “The presence of these vessels perpetuates the stimulus that generates the problem, and to treat them, it is important to be able to see them using 4x magnification. By performing the protocol as given in the correct order, these vessels will be revealed and thus visible to be treated in the fourth step.
“This is especially an issue in patients with an excessive amount of pigment or a higher skin phototype, where these vessels could not otherwise be seen clearly enough to assure thorough treatment,” Dr. Gaspar continued. “In such cases we hold off on this final step until the second or third session, when previous treatment has more clearly revealed these vessels. If you try to treat the vessels before you can see them you may either treat incompletely, or excessively deliver energy into the region which could cause hyperpigmentation rather than produce a therapeutically appropriate effect.”
Dr. Gaspar explained that this step uses the Nd:YAG in FRAC3 mode with the R28 handpiece, 6 ms pulse with a 2 mm spot at 160 to 210 J/cm2, or VERSA mode at a 10 ms pulse if the vessels are larger. “No other device on the market will do all these things in a single platform. Other Q-switched lasers simply cannot do what the StarWalker does and allow you to treat the vascular component in this manner.”
“In summary, using this four-step protocol with the StarWalker platform has enabled us to effectively address the inflammatory phenomenon, remove the pigment session-by-session, reduce vascularization in the area, recover tissue hemostasis and rejuvenate the dermis. This represents a complete treatment for melasma that maximally inhibits the potential for recurrence of the condition,” Dr. Gaspar noted. “Furthermore, post-inflammatory hyperpigmentation (PIH), overall, is mitigated by the protocol which is designed to treat specific aspects of melasma without causing unnecessary damage or buildup of heat.”