M. A. Bogle, MD
The Laser & Cosmetic Surgery Center of Houston; Department of Dermatology, the University of Texas MD Anderson Cancer Center; Department of Internal Medicine/Dermatology, St. Luke’s Episcopal Hospital, Houston, USA
Plasma skin regeneration (PSR) technology uses energy delivered from plasma rather than light or radiofrequency. Plasma is the fourth state of matter in which electrons are stripped from atoms to form an ionized gas. The plasma is emitted in a millisecond pulse to deliver energy to target tissue upon contact without reliance on skin chromophores. The technology can be used at varying energies for different depths of effect, from superficial epidermal sloughing to deeper dermal heating. With the Portrait® PSR device (Rhytec, Inc.) there are three treatment guidelines termed PSR1, PSR2, and PSR3. The PSR1 protocol uses a series of low-energy treatments (1.0–1.2 Joules) spaced 3 weeks apart. The PSR2 protocol uses one high-energy pass (3.0–4.0 Joules) performed in a single treatment, and the PSR3 protocol uses two high-energy passes (3.0–4.0 Joules) performed in a single treatment. All protocols improve fine lines, textural irregularities, and dyspigmentation; however, skin tightening is probably more pronounced with the high-energy treatments.
plasma skin regeneration, PSR
Plasma skin regeneration (PSR) technology can be used at varying energies for different depths of effect, from superficial epidermal sloughing to deeper dermal heating. In a pilot study evaluating the use of a single full-facial treatment at high energy (3–4 Joules), Kilmer, et al. demonstrated a mean improvement in overall facial rejuvenation of 50% by 1 month.1 Potter, et al. used silicone molding to demonstrate a 39% reduction in fine-line depth 6 months after one high energy, full-face treatment.2 Bogle, et al. evaluated a series of three low-energy (1.2–1.8 Joules), full-face treatments for facial rejuvenation and found a 37% improvement in facial rhytids at 3-month follow-up.3 In the same study, participants rated themselves as having a 68% improvement in overall facial rejuvenation at 3-month follow-up.3 Histologic analysis of posttreatment samples revealed a decrease in solar elastosis with significant new interdigitating collagen and thickening of the collagen band at the dermal-epidermal junction.3 The mean depth of new collagen formation was 72.3ìm.3 Epidermal thickness was not changed by the treatment.3
The Plasma Skin Regeneration Device
The PSR device consists of an ultra-high-frequency (UHF) radiofrequency generator that excites a tuned resonator and imparts energy to a flow of inert nitrogen gas within the handpiece. The activated, ionized gas is termed plasma. Nitrogen is used for the gaseous source because it is able to purge oxygen from the surface of the skin, minimizing the risk of unpredictable hot spots, charring, and scar formation. Upon formation, the plasma is directed through a quartz nozzle out of the tip of the handpiece and onto the skin. The plasma appears as a characteristic lilac glow that transitions to a yellowish light called a Lewis-Raleigh afterglow.
As the plasma hits the skin, energy is rapidly transferred to the skin surface, causing instantaneous heating in a controlled, uniform manner, without an explosive effect on tissue or epidermal removal. The depth and area of thermal effect are determined by the energy setting and spot size of the handpiece. The energy can be adjusted from 1–4 Joules per pulse. The intended spot size of 6mm is reached when the device is held approximately 5mm from the surface of the skin; however, the thermal effect can be increased or decreased by defocusing the handpiece either closer or farther away from the skin surface. High temperatures during each pulse erode the tungsten resonator in the handpiece, so the handpiece must be replaced after each use.
There are three recommended treatment guidelines, PSR1, PSR2, and PSR3. The PSR1 protocol uses a series of low-energy treatments spaced 3 weeks apart. The first treatment is performed at 1.0–1.2 Joules, and fluences are increased as tolerated at subsequent visits. Recovery time is 3–4 days. The PSR2 protocol uses one high-energy pass (3.0–4.0 Joules) with a recovery time of 5–7 days, and the PSR3 protocol uses two highenergy passes (3.0–4.0 Joules) with a recovery time of 6–10 days. A series of treatments in the mid-energy group (1.5–3.0 Joules) have produced good results in improving skin texture and discoloration, but they have only slightly less recovery time than a single highenergy treatment, and less skin tightening. Thus, most practitioners prefer to use the suggested PSR1, 2, or 3 protocols.
The first step in treatment is to assess the patient and determine the goals of treatment. Low-energy PSR1 treatments can normally be performed under local anesthesia with a topical agent. For mid-to-high energies, patients will require adjunctive oral anesthesia such as meperidine or a codeine derivative in addition to a topical agent. Patients should arrive at least 1 hour beforehand so that the topical anesthetic cream can be applied and left on for approximately 1 hour. Oral anesthesia should be administered 30–45 minutes before the procedure begins. To avoid unexpected downtime, it is important for the physician to develop a standard protocol for removal of topical anesthesia and delay time before starting the procedure. Hydration of the epidermis influences the amount of energy that is absorbed and the depth of thermal insult achieved, with drier tissue absorbing more energy.4
Generally, it is a good idea to work in aesthetic segments of the face (i.e., forehead, nose, cheek, chin, etc.), removing the anesthetic cream for each area immediately before treating that area rather than removing the cream for the entire face all at once. This helps to standardize the delay time between anesthetic removal and treatment. Anesthetic should be gently wiped off with dry gauze. Again, it is not necessary to use water or alcohol-soaked gauze as this will change the hydration properties of the skin.
Once a facial segment is ready for treatment, the tip of the handpiece should be held approximately 5mm from the skin’s surface. (Figure 1) The pulses are delivered in a paintbrush fashion in one direction across the treatment area. The pulses should be delivered in rows of one direction (either all right to left, or all left to right) because a zig-zag pattern has been found to cause heat build-up at the corners where one changes direction to start the subsequent row. Pulses should not be overlapped more than about 10%. To avoid lines of demarcation in the high-energy protocol, the borders of the treatment area should be feathered by increasing the distance of the nozzle from the surface of the skin to about 1cm. Feathering can also be achieved by holding the handpiece nozzle at an angle with respect to the skin surface or reducing the power setting. There is no need for feathering in the low-energy PSR1 protocol.
Patients should be instructed to avoid sun exposure and apply a bland ointment to the face at frequent intervals after the procedure while the skin is healing. Lowenergy PSR1 treatments may cause only erythema for 2–3 days. High-energy treatments will cause erythema and a “dirty” look to the skin, which will resolve in 5–10 days as re-epithelialization occurs and the photodamaged epidermis sloughs off. It is important for patients not to manually pick at the peeling skin to avoid prolonged erythema or scarring.
There have been no major side-effects reported in studies to date. As in all procedures utilizing heat energy, side-effects that could occur include erythema, edema, epidermal de-epithelialization, scarring, and hyperpigmentation. There have been no reported instances of hypopigmentation. Erythema and edema are common postprocedure, usually resolving in several days. Edema can be decreased by the application of ice following the procedure. Epidermal de-epithelialization is a risk at higher energies and should be treated with appropriate wound care and liberal application of a bland ointment. Temporary hyperpigmentation has been reported at mid-to-high energy treatments. Scarring is rare.
Plasma skin regeneration technology is a novel method to rejuvenate the skin and has shown good results in the improvement of fine lines, dyspigmentation, and textural irregularities. High-energy protocols can offer the added benefit of increased tissue tightening. The treatments are safe and no major side-effects have yet been reported.
- Kilmer S, Fitzpatrick R, Bernstein E, Brown D. Long term follow-up on the use of plasma skin regeneration (PSR) in full facial rejuvenation procedures. Lasers Surg Med 36(Suppl 17):22 (2005).
- Potter M, Harrison R, Ramsden A, Andrews P, Gault D. Facial acne and fine lines: transforming patient outcomes with plasma skin resurfacing. Lasers Surg Med 36(Suppl 17):23 (2005).
- Bogle MA, Arndt KA, Dover JS. Evaluation of plasma skin regeneration technology in low fluence full-facial rejuvenation. Arch Dermatol (In Press, 2006).
- Penny K, Sibbons P, Andrews P, Southgate A. A histopathologic assessment of the effects
of hydration on the absorption of plasma skin regeneration energy (PSR) in an animal model. Lasers Surg Med (In Press, 2006).