This case demonstrates that utilizing fractionated CO2 laser on the arms and legs can impressively rejuvenate photodamaged skin.
Several resurfacing modalities are currently available to improve the appearance of photodamaged skin. Among the myriad of options is the fractionated carbon dioxide (CO2) laser. The fractionated CO2 laser has shown superiority in treating rhytides, reducing or eliminating pigmentary irregularities and improving skin tightness.1 This treatment method accomplishes such results by creating an array of micro-thermal zones of variable densities and depths, while producing a confluent pattern of ablation and coagulation of the epidermis and a portion of the dermis.2 Many reports that have been published in recent years illustrate the effectiveness of the fractionated CO2 laser on the face, neck, chest and even the hands.1,3-6 We present a case that utilized fractionated CO2 laser on the arms and legs, which impressively rejuvenated photodamaged skin.
Case
A 67-year-old Caucasian female (Fitzpatrick skin type III) presented with concern about the appearance of her arms and legs. Her specific request was to improve laxity, fine and deep wrinkling and dyspigmentation. Her past medical history was significant only for non-melanoma skin cancer. Physical examination of the proximal aspects of her arms and legs revealed advanced photodamage, Glogau classification III, including both fine and deep wrinkling, loss of elasticity, skin yellowing and several variably sized tan and brown lentigines (Figures 1A and 1B, left to right).
Treatment Protocol
The photodamaged areas of the arms and legs were cleansed with mild soap and water. For the patient’s first treatment, she was given moderate sedation, as she was simultaneously undergoing other cosmetic procedures. Both the arms and legs were treated with a single pass of the Coherent 5000 Ultrapulse fractionated CO2 laser. The settings used for the first treatment were as follows: 40 watts, 30 millijoules, density of 1, diamond pattern on size 9 and no overlapping. We delivered contiguous pulses, with the endpoint of whitening noted after each pulse. The entire laser treatment time of the arms and legs was approximately 20 minutes. At the conclusion of the procedure, we placed gauze soaked in normal saline over the arms and legs to gently remove ablated skin tissue, and then we applied a thin layer of Aquaphor ointment. The patient was instructed to cover the treated areas with Aquaphor ointment three to four times daily until bright erythema had resolved. Strict sun avoidance was also advised for four weeks following the procedure. The patient underwent a second treatment approximately eight weeks later. In preparation for this treatment, LMX 4% topical anesthetic cream was applied to the treatment sites approximately one hour prior to the procedure. The settings used for her second treatment were identical to the first.
Evaluation
Photographs were taken at baseline (pre-treatment) and at six months (post-treatment). Pre- and post-treatment photographs were evaluated by two of the authors and two independent physicians for degree of improvement in skin tightness, wrinkle reduction and skin pigmentation on a 4-point scale: 0%-25% (no or minimal improvement); 25%-50% (mild improvement); 50%-75% (very good improvement); 75%-100% (excellent improvement). The patient was also asked to rate her perception of global improvement on a similar scale.
Results
The patient tolerated both treatments very well, reporting minimal pain after using topical anesthesia alone on the second treatment. Healing time lasted approximately 2 weeks, showing mild-to-moderate skin erythema and minimal skin crusting. At the 6-month follow-up visit, there was no scarring noted and no evidence of hyperpigmentation or hypopigmentation.
Cosmetic improvement overall was very good, with all four physicians assigning a rating of 50%-75% improvement in wrinkle reduction, skin tightening and pigmentation improvement on her 6-month photographs compared to baseline. Also, the patient’s perception of improvement was excellent, noting a 75% improvement or higher (Figures 2A and 2B, left to right).
Discussion
Ultraviolet (UV) irradiation from the sun damages skin and results in premature aging. This process, known as photoaging, is cumulative with sun exposure.7 The photoaged phenotype is characterized by fine and course wrinkles, mottled pigmentation, dull color and uneven texture. These changes occur as a direct result of UV irradiation causing disarrangement and damage of the dermal extracellular matrix.8 Collagen fibrils become haphazardly arranged, elastic fibers are degraded and become tangled, blood vessels are dilated and tortuous, the epidermis becomes focally atrophic and melanocytes are irregularly dispersed along the basement membrane.9
These manifestations of photoaging can be markedly improved with the fractionated CO2 laser. The laser works on the principle of combining tissue ablation and coagulation with fractional photothermolysis.10 Fractional photothermolysis is the creation of micro-thermal zones or columns of controlled thermal injury, in an evenly spaced pattern, surrounded by healthy untreated skin.2 This results in tissue contraction, collagen production, dermal remodeling and re-epithelization to produce desired results.
The fractionated CO2 laser has been instrumental in improving photoaging on various sites of the body. Tierney and Hanke reported a significant improvement in photoaging of the face using the fractionated CO2 laser in a series of 2-3 treatments at 8-week intervals.6 In a similar study, the same authors also found neck skin tightening after a series of one or two treatments.2 Stebbins and Hanke showed significant improvements in wrinkling, pigmentation and texture over three treatments using the fractionated CO2 laser on the photodamaged hands of 10 women.1
Notably, here we have demonstrated that the fractionated CO2 laser is very beneficial in reversing the signs of photoaging on the arms and legs. Our patient showed significant improvements in both fine and deep wrinkles and acquired firmer skin over two treatment sessions. Physician improvement ratings revealed a 50%-75% improvement and the patient’s global satisfaction assessment was excellent. Overall, the treatments were well tolerated and they had a salubrious effect.
We elected to treat her with similar settings one would consider for the neck. Despite using these settings, we did not encounter any immediate or delayed side effects such as hypopigmentation, hyperpigmentation or scarring. This is a distinct advantage over the traditional CO2 laser. We conclude that this novel case illustrates the efficacy of the fractionated CO2 in improving photodamage on the arms and legs.
Dr. Torres is a practicing dermatologist at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ, as well as a Mohs and cosmetic surgeon. He also teaches Mohs and cosmetic surgery in a Procedural Dermatology Fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME).
Dr. Kirkland is a dermatology fellow at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ.
Dr. Rogachefsky is a practicing dermatologist and the Program Director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ.
Disclosure: The authors disclose that they have no real or apparent conflicts of interest or financial interests or arrangements with any companies or products mentioned in this article.
References
1. Stebbins WG, Hanke CW. Ablative fractional CO2 resurfacing for photoaging of the hands: Pilot study of 10 patients. Dermatol Ther. 2011;24(1):62-70.
2. Tierney EP, Eisen RF, Hanke CW. Fractionated CO2 laser skin rejuvenation. Dermatol Ther. 2011;24(1):41-53.
3. Hunzeker CM, Weiss ET, Geronemus RG. Fractionated CO2 laser resurfacing: Our experience with more than 2000 treatments. Aesthet Surg J. 2009;29(4):317-322.
4. Sasaki GH, Travis HM, Tucker B. Fractional CO2 laser resurfacing of photo aged facial and non-facial skin: Histologic and clinical results and side effects. J Cosmet Laser Ther. 2009;11(4):190-201.
5. Tierney EP, Hanke CW, Petersen J. Ablative fractionated CO2 laser treatment of photo aging: A clinical and histologic study. Dermatol Surg. 2012;38(11):1777-1789.
6. Tierney EP, Hanke CW. Fractionated carbon dioxide laser treatment of photoaging: Prospective study in 45 patients and review of the literature. Dermatol Surg. 2011;37(9):1279-1290.
7. Fisher GJ, Kang S, Varani J, et al. Mechanisms of photoaging and chronological skin aging. Arch Dermatol. 2002;138(11):1462-1470.
8. Kang S, Fisher GJ, Voorhees JJ. Photoaging: Pathogenesis, prevention and treatment. Clin Geriatr Med. 2001;17(4):643-659, v-vi.
9. Gilchrest BA. Skin aging and photoaging: An overview. J Am Acad Dermatol. 1989;21(3 Pt 2):610-613.
10. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional photothermolysis: A new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med. 2004;34(5):426-438.
This case demonstrates that utilizing fractionated CO2 laser on the arms and legs can impressively rejuvenate photodamaged skin.
Several resurfacing modalities are currently available to improve the appearance of photodamaged skin. Among the myriad of options is the fractionated carbon dioxide (CO2) laser. The fractionated CO2 laser has shown superiority in treating rhytides, reducing or eliminating pigmentary irregularities and improving skin tightness.1 This treatment method accomplishes such results by creating an array of micro-thermal zones of variable densities and depths, while producing a confluent pattern of ablation and coagulation of the epidermis and a portion of the dermis.2 Many reports that have been published in recent years illustrate the effectiveness of the fractionated CO2 laser on the face, neck, chest and even the hands.1,3-6 We present a case that utilized fractionated CO2 laser on the arms and legs, which impressively rejuvenated photodamaged skin.
Case
A 67-year-old Caucasian female (Fitzpatrick skin type III) presented with concern about the appearance of her arms and legs. Her specific request was to improve laxity, fine and deep wrinkling and dyspigmentation. Her past medical history was significant only for non-melanoma skin cancer. Physical examination of the proximal aspects of her arms and legs revealed advanced photodamage, Glogau classification III, including both fine and deep wrinkling, loss of elasticity, skin yellowing and several variably sized tan and brown lentigines (Figures 1A and 1B, left to right).
Treatment Protocol
The photodamaged areas of the arms and legs were cleansed with mild soap and water. For the patient’s first treatment, she was given moderate sedation, as she was simultaneously undergoing other cosmetic procedures. Both the arms and legs were treated with a single pass of the Coherent 5000 Ultrapulse fractionated CO2 laser. The settings used for the first treatment were as follows: 40 watts, 30 millijoules, density of 1, diamond pattern on size 9 and no overlapping. We delivered contiguous pulses, with the endpoint of whitening noted after each pulse. The entire laser treatment time of the arms and legs was approximately 20 minutes. At the conclusion of the procedure, we placed gauze soaked in normal saline over the arms and legs to gently remove ablated skin tissue, and then we applied a thin layer of Aquaphor ointment. The patient was instructed to cover the treated areas with Aquaphor ointment three to four times daily until bright erythema had resolved. Strict sun avoidance was also advised for four weeks following the procedure. The patient underwent a second treatment approximately eight weeks later. In preparation for this treatment, LMX 4% topical anesthetic cream was applied to the treatment sites approximately one hour prior to the procedure. The settings used for her second treatment were identical to the first.
Evaluation
Photographs were taken at baseline (pre-treatment) and at six months (post-treatment). Pre- and post-treatment photographs were evaluated by two of the authors and two independent physicians for degree of improvement in skin tightness, wrinkle reduction and skin pigmentation on a 4-point scale: 0%-25% (no or minimal improvement); 25%-50% (mild improvement); 50%-75% (very good improvement); 75%-100% (excellent improvement). The patient was also asked to rate her perception of global improvement on a similar scale.
Results
The patient tolerated both treatments very well, reporting minimal pain after using topical anesthesia alone on the second treatment. Healing time lasted approximately 2 weeks, showing mild-to-moderate skin erythema and minimal skin crusting. At the 6-month follow-up visit, there was no scarring noted and no evidence of hyperpigmentation or hypopigmentation.
Cosmetic improvement overall was very good, with all four physicians assigning a rating of 50%-75% improvement in wrinkle reduction, skin tightening and pigmentation improvement on her 6-month photographs compared to baseline. Also, the patient’s perception of improvement was excellent, noting a 75% improvement or higher (Figures 2A and 2B, left to right).
Discussion
Ultraviolet (UV) irradiation from the sun damages skin and results in premature aging. This process, known as photoaging, is cumulative with sun exposure.7 The photoaged phenotype is characterized by fine and course wrinkles, mottled pigmentation, dull color and uneven texture. These changes occur as a direct result of UV irradiation causing disarrangement and damage of the dermal extracellular matrix.8 Collagen fibrils become haphazardly arranged, elastic fibers are degraded and become tangled, blood vessels are dilated and tortuous, the epidermis becomes focally atrophic and melanocytes are irregularly dispersed along the basement membrane.9
These manifestations of photoaging can be markedly improved with the fractionated CO2 laser. The laser works on the principle of combining tissue ablation and coagulation with fractional photothermolysis.10 Fractional photothermolysis is the creation of micro-thermal zones or columns of controlled thermal injury, in an evenly spaced pattern, surrounded by healthy untreated skin.2 This results in tissue contraction, collagen production, dermal remodeling and re-epithelization to produce desired results.
The fractionated CO2 laser has been instrumental in improving photoaging on various sites of the body. Tierney and Hanke reported a significant improvement in photoaging of the face using the fractionated CO2 laser in a series of 2-3 treatments at 8-week intervals.6 In a similar study, the same authors also found neck skin tightening after a series of one or two treatments.2 Stebbins and Hanke showed significant improvements in wrinkling, pigmentation and texture over three treatments using the fractionated CO2 laser on the photodamaged hands of 10 women.1
Notably, here we have demonstrated that the fractionated CO2 laser is very beneficial in reversing the signs of photoaging on the arms and legs. Our patient showed significant improvements in both fine and deep wrinkles and acquired firmer skin over two treatment sessions. Physician improvement ratings revealed a 50%-75% improvement and the patient’s global satisfaction assessment was excellent. Overall, the treatments were well tolerated and they had a salubrious effect.
We elected to treat her with similar settings one would consider for the neck. Despite using these settings, we did not encounter any immediate or delayed side effects such as hypopigmentation, hyperpigmentation or scarring. This is a distinct advantage over the traditional CO2 laser. We conclude that this novel case illustrates the efficacy of the fractionated CO2 in improving photodamage on the arms and legs.
Dr. Torres is a practicing dermatologist at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ, as well as a Mohs and cosmetic surgeon. He also teaches Mohs and cosmetic surgery in a Procedural Dermatology Fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME).
Dr. Kirkland is a dermatology fellow at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ.
Dr. Rogachefsky is a practicing dermatologist and the Program Director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ.
Disclosure: The authors disclose that they have no real or apparent conflicts of interest or financial interests or arrangements with any companies or products mentioned in this article.
References
1. Stebbins WG, Hanke CW. Ablative fractional CO2 resurfacing for photoaging of the hands: Pilot study of 10 patients. Dermatol Ther. 2011;24(1):62-70.
2. Tierney EP, Eisen RF, Hanke CW. Fractionated CO2 laser skin rejuvenation. Dermatol Ther. 2011;24(1):41-53.
3. Hunzeker CM, Weiss ET, Geronemus RG. Fractionated CO2 laser resurfacing: Our experience with more than 2000 treatments. Aesthet Surg J. 2009;29(4):317-322.
4. Sasaki GH, Travis HM, Tucker B. Fractional CO2 laser resurfacing of photo aged facial and non-facial skin: Histologic and clinical results and side effects. J Cosmet Laser Ther. 2009;11(4):190-201.
5. Tierney EP, Hanke CW, Petersen J. Ablative fractionated CO2 laser treatment of photo aging: A clinical and histologic study. Dermatol Surg. 2012;38(11):1777-1789.
6. Tierney EP, Hanke CW. Fractionated carbon dioxide laser treatment of photoaging: Prospective study in 45 patients and review of the literature. Dermatol Surg. 2011;37(9):1279-1290.
7. Fisher GJ, Kang S, Varani J, et al. Mechanisms of photoaging and chronological skin aging. Arch Dermatol. 2002;138(11):1462-1470.
8. Kang S, Fisher GJ, Voorhees JJ. Photoaging: Pathogenesis, prevention and treatment. Clin Geriatr Med. 2001;17(4):643-659, v-vi.
9. Gilchrest BA. Skin aging and photoaging: An overview. J Am Acad Dermatol. 1989;21(3 Pt 2):610-613.
10. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional photothermolysis: A new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med. 2004;34(5):426-438.
This case demonstrates that utilizing fractionated CO2 laser on the arms and legs can impressively rejuvenate photodamaged skin.
Several resurfacing modalities are currently available to improve the appearance of photodamaged skin. Among the myriad of options is the fractionated carbon dioxide (CO2) laser. The fractionated CO2 laser has shown superiority in treating rhytides, reducing or eliminating pigmentary irregularities and improving skin tightness.1 This treatment method accomplishes such results by creating an array of micro-thermal zones of variable densities and depths, while producing a confluent pattern of ablation and coagulation of the epidermis and a portion of the dermis.2 Many reports that have been published in recent years illustrate the effectiveness of the fractionated CO2 laser on the face, neck, chest and even the hands.1,3-6 We present a case that utilized fractionated CO2 laser on the arms and legs, which impressively rejuvenated photodamaged skin.
Case
A 67-year-old Caucasian female (Fitzpatrick skin type III) presented with concern about the appearance of her arms and legs. Her specific request was to improve laxity, fine and deep wrinkling and dyspigmentation. Her past medical history was significant only for non-melanoma skin cancer. Physical examination of the proximal aspects of her arms and legs revealed advanced photodamage, Glogau classification III, including both fine and deep wrinkling, loss of elasticity, skin yellowing and several variably sized tan and brown lentigines (Figures 1A and 1B, left to right).
Treatment Protocol
The photodamaged areas of the arms and legs were cleansed with mild soap and water. For the patient’s first treatment, she was given moderate sedation, as she was simultaneously undergoing other cosmetic procedures. Both the arms and legs were treated with a single pass of the Coherent 5000 Ultrapulse fractionated CO2 laser. The settings used for the first treatment were as follows: 40 watts, 30 millijoules, density of 1, diamond pattern on size 9 and no overlapping. We delivered contiguous pulses, with the endpoint of whitening noted after each pulse. The entire laser treatment time of the arms and legs was approximately 20 minutes. At the conclusion of the procedure, we placed gauze soaked in normal saline over the arms and legs to gently remove ablated skin tissue, and then we applied a thin layer of Aquaphor ointment. The patient was instructed to cover the treated areas with Aquaphor ointment three to four times daily until bright erythema had resolved. Strict sun avoidance was also advised for four weeks following the procedure. The patient underwent a second treatment approximately eight weeks later. In preparation for this treatment, LMX 4% topical anesthetic cream was applied to the treatment sites approximately one hour prior to the procedure. The settings used for her second treatment were identical to the first.
Evaluation
Photographs were taken at baseline (pre-treatment) and at six months (post-treatment). Pre- and post-treatment photographs were evaluated by two of the authors and two independent physicians for degree of improvement in skin tightness, wrinkle reduction and skin pigmentation on a 4-point scale: 0%-25% (no or minimal improvement); 25%-50% (mild improvement); 50%-75% (very good improvement); 75%-100% (excellent improvement). The patient was also asked to rate her perception of global improvement on a similar scale.
Results
The patient tolerated both treatments very well, reporting minimal pain after using topical anesthesia alone on the second treatment. Healing time lasted approximately 2 weeks, showing mild-to-moderate skin erythema and minimal skin crusting. At the 6-month follow-up visit, there was no scarring noted and no evidence of hyperpigmentation or hypopigmentation.
Cosmetic improvement overall was very good, with all four physicians assigning a rating of 50%-75% improvement in wrinkle reduction, skin tightening and pigmentation improvement on her 6-month photographs compared to baseline. Also, the patient’s perception of improvement was excellent, noting a 75% improvement or higher (Figures 2A and 2B, left to right).
Discussion
Ultraviolet (UV) irradiation from the sun damages skin and results in premature aging. This process, known as photoaging, is cumulative with sun exposure.7 The photoaged phenotype is characterized by fine and course wrinkles, mottled pigmentation, dull color and uneven texture. These changes occur as a direct result of UV irradiation causing disarrangement and damage of the dermal extracellular matrix.8 Collagen fibrils become haphazardly arranged, elastic fibers are degraded and become tangled, blood vessels are dilated and tortuous, the epidermis becomes focally atrophic and melanocytes are irregularly dispersed along the basement membrane.9
These manifestations of photoaging can be markedly improved with the fractionated CO2 laser. The laser works on the principle of combining tissue ablation and coagulation with fractional photothermolysis.10 Fractional photothermolysis is the creation of micro-thermal zones or columns of controlled thermal injury, in an evenly spaced pattern, surrounded by healthy untreated skin.2 This results in tissue contraction, collagen production, dermal remodeling and re-epithelization to produce desired results.
The fractionated CO2 laser has been instrumental in improving photoaging on various sites of the body. Tierney and Hanke reported a significant improvement in photoaging of the face using the fractionated CO2 laser in a series of 2-3 treatments at 8-week intervals.6 In a similar study, the same authors also found neck skin tightening after a series of one or two treatments.2 Stebbins and Hanke showed significant improvements in wrinkling, pigmentation and texture over three treatments using the fractionated CO2 laser on the photodamaged hands of 10 women.1
Notably, here we have demonstrated that the fractionated CO2 laser is very beneficial in reversing the signs of photoaging on the arms and legs. Our patient showed significant improvements in both fine and deep wrinkles and acquired firmer skin over two treatment sessions. Physician improvement ratings revealed a 50%-75% improvement and the patient’s global satisfaction assessment was excellent. Overall, the treatments were well tolerated and they had a salubrious effect.
We elected to treat her with similar settings one would consider for the neck. Despite using these settings, we did not encounter any immediate or delayed side effects such as hypopigmentation, hyperpigmentation or scarring. This is a distinct advantage over the traditional CO2 laser. We conclude that this novel case illustrates the efficacy of the fractionated CO2 in improving photodamage on the arms and legs.
Dr. Torres is a practicing dermatologist at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ, as well as a Mohs and cosmetic surgeon. He also teaches Mohs and cosmetic surgery in a Procedural Dermatology Fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME).
Dr. Kirkland is a dermatology fellow at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ.
Dr. Rogachefsky is a practicing dermatologist and the Program Director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ.
Disclosure: The authors disclose that they have no real or apparent conflicts of interest or financial interests or arrangements with any companies or products mentioned in this article.
References
1. Stebbins WG, Hanke CW. Ablative fractional CO2 resurfacing for photoaging of the hands: Pilot study of 10 patients. Dermatol Ther. 2011;24(1):62-70.
2. Tierney EP, Eisen RF, Hanke CW. Fractionated CO2 laser skin rejuvenation. Dermatol Ther. 2011;24(1):41-53.
3. Hunzeker CM, Weiss ET, Geronemus RG. Fractionated CO2 laser resurfacing: Our experience with more than 2000 treatments. Aesthet Surg J. 2009;29(4):317-322.
4. Sasaki GH, Travis HM, Tucker B. Fractional CO2 laser resurfacing of photo aged facial and non-facial skin: Histologic and clinical results and side effects. J Cosmet Laser Ther. 2009;11(4):190-201.
5. Tierney EP, Hanke CW, Petersen J. Ablative fractionated CO2 laser treatment of photo aging: A clinical and histologic study. Dermatol Surg. 2012;38(11):1777-1789.
6. Tierney EP, Hanke CW. Fractionated carbon dioxide laser treatment of photoaging: Prospective study in 45 patients and review of the literature. Dermatol Surg. 2011;37(9):1279-1290.
7. Fisher GJ, Kang S, Varani J, et al. Mechanisms of photoaging and chronological skin aging. Arch Dermatol. 2002;138(11):1462-1470.
8. Kang S, Fisher GJ, Voorhees JJ. Photoaging: Pathogenesis, prevention and treatment. Clin Geriatr Med. 2001;17(4):643-659, v-vi.
9. Gilchrest BA. Skin aging and photoaging: An overview. J Am Acad Dermatol. 1989;21(3 Pt 2):610-613.
10. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional photothermolysis: A new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med. 2004;34(5):426-438.
A 67-year-old Caucasian female (Fitzpatrick skin type III) presented with concern about the appearance of her arms and legs. Her specific request was to improve laxity, fine and deep wrinkling and dyspigmentation. Her past medical history was significant only for non-melanoma skin cancer. Physical examination of the proximal aspects of her arms and legs revealed advanced photodamage, Glogau classification III, including both fine and deep wrinkling, loss of elasticity, skin yellowing and several variably sized tan and brown lentigines (Figures 1A and 1B, left to right). 
Cosmetic improvement overall was very good, with all four physicians assigning a rating of 50%-75% improvement in wrinkle reduction, skin tightening and pigmentation improvement on her 6-month photographs compared to baseline. Also, the patient’s perception of improvement was excellent, noting a 75% improvement or higher (Figures 2A and 2B, left to right).
