Received: 7 November 2016 | Revised: 4 January 2017 | Accepted: 10 January 2017

DOI 10.1111/dth.12470

ORIGINAL PAPERS

Mexametric and cutometric assessment of the signs of aging

of the skin area around the eyes after the use of non-ablative
fractional laser, non-ablative radiofrequency and intense
pulsed light

Anna Maria Kołodziejczak | Helena Rotsztejn

Department of Cosmetology and Aesthetic

Dermatology, Faculty of Pharmacy, Medical
University of Lo
d
z, Muszyn

skiego 1 Street,
91 - 151 Ło
d
z, Poland
Correspondence
Anna Augustyniak, Department of
Cosmetology and Aesthetic Dermatology,
Faculty of Pharmacy, Medical University of

d
z, Muszyn
Ło
skiego 1 Street, 91-151 Ło

d
z,
Poland.
Email: anna.maria.augustyniak@umed.lodz.pl
Funding information
Department of Cosmetology and Aesthetic
Dermatology, Faculty of Pharmacy, Medical
University of Lodz, Grant/Award numbers:
503/3-066-01/503-31-001 and 502-03/3-
066-01/502-34-059
Abstract
The assessment of the signs of aging within eyes area in cutometric (skin elasticity) and mexamet-
ric (discoloration and severity of erythema) examination after the treatment with: non-ablative
fractional laser, non-ablative radiofrequency (RF) and intense light source (IPL). This study included
71 patients, aged 33–63 years (the average age was 45.81) with Fitzpatrick skin type II and III. 24
patients received 5 successive treatment sessions with a 1,410-nm non-ablative fractional laser in
two-week intervals, 23 patients received 5 successive treatment sessions with a non-ablative RF
in one-week intervals and 24 patients received 5 successive treatment sessions with an IPL in
two-week intervals. The treatment was performed for the skin in the eye area. The Cutometer
and Mexameter (Courage 1 Khazaka electronic) reference test was used as an objective method
for the assessment of skin properties: elasticity, skin pigmentation and erythema. Measurements
of skin elasticity were made in three or four sites within eye area. The results of cutometric meas-
urements for R7 showed the improvement in skin elasticity in case of all treatment methods. The
largest statistically significant improvement (p < .0001) was observed in case of laser and RF, dur-
ing treatment sessions, at sites at upper and lower eyelid. The smallest change in skin elasticity for
the laser, RF and IPL – p 5 .017, p 5 .003 and p 5 .001, respectively—was observed in a site within
the outer corner of the eye. In all sites of measurements and for all methods, the greatest improve-
ment in skin elasticity was demonstrated between the first and second measurement (after 3rd
procedures). The majority of the results of mexametric measurements—MEX (melanin level) and
ERYT (the severity of erythema) are statistically insignificant. Fractional, non-ablative laser, non-
ablation RF and intense light source can be considered as methods significantly affecting elasticity
and to a lesser extent erythema and skin pigmentation around the eyes. Fractional non-ablative
laser is a method which, in comparison to other methods, has the greatest impact on skin viscoe-
lasticity. These procedures are well tolerated and are associated with a low risk of side effects.

KEYWORDS
cutometer, intense pulsed light, mexameter, non-ablative fractional laser, non-ablative radiofre-
quency, skin aging

1 | INTRODUCTION
The skin around eyes is characterized by specific conditions of con-
struction: smoothed dermal-epidermal border, thin dermis (lower
amount of collagen, elastin, and glycosaminoglycans than other areas
of the face) and low density of sebaceous glands. Moreover, the subcu-
taneous tissue is thin and superficially located. Owing to these factors,
the skin around the eyes is dry, inelastic, prone to skin discolorations,
true, pigmented and vascular dark circles and the formation of fat
“bags” under the eyes. Moreover, wrinkles characteristic for lateral can-
thus named “crow’s feet” are formed here as a result of overactivity of
the orbital part of orbicularis oculi muscle. Muscles surrounding the

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C 2017 Wiley Periodicals, Inc. | 1 of 9
https://doi.org/10.1111/dth.12470
2 of 9 | AUGUSTYNIAK
palpebral fissure are among the most active mimic muscles contributing
to the formation of wrinkles.
A dynamic advancement in the range of recommended solutions
provide numerous methods which are used to correct symptoms of
skin aging in the eye area. In our study, the influence of non-ablative
fractional laser, non-ablative radiofrequency (RF) and intense pulsed
light (IPL) on the elasticity, pigmentation and erythema in the area of
eyes has been assessed. The activation of thermal response within der-
mis where the subsequent remodeling process characterized by the
deposition of new collagen occur, is the target of these methods.
2 | MATERIALS AND METHODS
2.1 | Material
This study included 71 patients, aged 33–63 years (the average age
was 45.81) with Fitzpatrick skin type II and III. 24 patients received 5
successive treatment sessions with a 1,410-nm non-ablative fractional
laser in two-week intervals, 23 patients received 5 successive treat-
ment sessions with a non-ablative RF in one-week intervals and 24
patients received 5 successive treatment sessions with an IPL in two-
week intervals. The treatment was performed on the skin within the
eye area. There were no contraindications for treatment. None of
patients had been enrolled into any other cosmetology or aesthetic
dermatology study before. Each patient was provided with detailed
information regarding post-treatment behavior, for example UV protec-
tion, using a cosmetic for daily care—Alantandermoline light cream
with 5% content of d-panthenol which was supposed to minimize any
potential side effects.
2.2 | Methods
2.2.1 | Non-ablative fractional laser
The procedure was conducted with the use of 1,410-nm non-ablative
fractional diode laser (Emerge, Palomar). The laser is consistent with
Class II Medical Device (USA), Class IIb (UE), Class 1M and IEC 60825-
1:2007. Treatment parameters were selected individually according to
the patient’s Fitzpatrick’s phototype. During treatment, the patient had
secured eyes by safety laser eye shields. The following schemes were
used: patients with medium and dark phototype III and light phototype
IV—energy beam of 20 mJ/lC, concentration pattern 8 3 5, the num-
ber of micro columns in scanning surface unit—40, the distance
between the micro columns—1.5 mm; patients with I and II phototype
and light phototype III: energy beam of 25 mJ/lC, concentration pat-
tern 9 3 6, the number of micro columns in the scanning surface unit—
54, the distance between the micro columns—1.3 mm; patients with I
and II phototype: energy beam of 30 mJ/lC, concentration pattern 10
3 7, the number of micro columns in the scanning surface unit—70,
the distance the between micro columns—1.1 mm. The temperature of
skin warming-up during the procedure depended on many factors,
including: the type of used energy, disposition and depth of columns as
well as the thickness and hydration of target areas of epidermis and
AND ROTSZTEJN
dermis. Processes occurring as a result of the treatment indicated that
maximal reached temperature was 60–658C.
2.2.2 | Non-ablative radiofrequency
The procedure was conducted with the use of non-ablative bipolar RF
(Thermalipo II, Thermamedic), which is an Automatic Multi-Frequency
and Low Impedance (AMFLI) technology. During this procedure, we
used appropriate time and temperature of the heating (temperature of
epidermis reached to 40–428C), which was selected according to the
individual patient’s pain tolerance. The frequencies of the treatment
are as follows: 1.8 MHz, 2.7 MHz, and 3.6 MHz. The device generates
considerable power at 200 W. Eye shields were not used due to the
fact that the treatment was directed toward the area of outside the
orbital rim. Conductor gel was applied on the skin during the
procedure.
2.2.3 | Intense pulsed light
The procedure was conducted with IPL device which emitted light in
the range of 530–1,200 nm (MIMARI HM-IPL-B1). During treatment,
the patient had secured eyes by safety laser eye shields. Treatment
parameters varied due to different treatment response of each patient:
the energy density (fluence) ranged from 10 to 50 J⁄cm2, sequence of
impulses: 1–5 impulses, time of the impulse: 2–15 ms, impulse delay:
5–60 ms, repeatability: 0.3–1Hz. Moreover, parameters were adjusted
individually according to the patient’s Fitzpatrick’s phototype. The tem-
perature of the glass transmission block did not exceed 458C (Ash,
Town, & Martin, 2007).
Mexameter MX 18 (Courage 1 Khazaka electronic) is a non-
invasive device used to measure the concentration of melanin and hae-
moglobin in a skin. The measurement is made using the phenomenon
of light absorption. A special probe emits three different wavelengths
and the receptor measures the light reflected from the skin. Since the
amount of emitted light is determined accurately, it is possible to calcu-
late the amount of light absorbed by the skin. Wavelengths were cho-
sen to achieve different levels of absorption by the pigment melanin
and hemoglobin.
Cutometer (Courage 1 Khazaka electronic) is a non-invasive device
used to evaluate biomechanical properties of skin. It measures elasticity
of the upper skin layer using negative pressure which deforms the skin
mechanically. In our study, the following parameters of the measure-
ment were used: measurement mode 1, negative pressure 450 mbar,
on-time 3 s, off-time 3 s, repetitions 3. We analyzed R7 parameter. R7
and R2 are used as primary Cutometer parameters for the assessment
of skin elasticity and aging. R7 refers to biological elasticity, and it
relates elasticity with final distension. This parameter is represented by
the ratio of “immediate retraction” to “final distension,” i.e., Ur/Uf. R7
decreases with aging (skin firmness 5> 1). Additionally, we analyzed
parameters R2 and R6. R2 refers to gross-elasticity of the skin, includ-
ing viscous deformation and is represented by the ratio of “the ability
of skin re-deformation” to “final distension,” i.e., Ua/Uf. R6 parameter
indicates a relative contribution of viscoelastic, viscous and elastic
deformation to total deformation and is represented by the ratio of
“viscoelastic distension” to “elastic distension,” i.e.; Uv/Ue.
AUGUSTYNIAK AND ROTSZTEJN
Cutometer and Mexameter allowed the evaluation of changes
before and after cosmetology or aesthetic dermatology treatments.
To reduce the impact of external factors on the measurement results, the
subjects did not use any cosmetics within 6 hr before the treatment.
Cutometric measurements were made according to the scheme: (a)—
before the series of treatment (immediately before the first treatment),
(b)—after three series of treatment (immediately before the fourth treat-
ment), (c)—after five treatments (two weeks after the fifth treatment),
and (d)—three months after the end of the series. Mexametric measure-
ments were performed before all 5 treatments and two weeks after the
fifth treatment. Measurements in case of laser and RF treatments, were
made within four places in the eye area: first place (A) in 1/3 of the
length of superciliary arch on the upper eyelid, second place (B) two cen-
timeters in a straight line from the outer corner of the eye, third place (C)
2 cm from the pupil on the lower eyelid, fourth place (D) 2 cm down
from the outer corner of the eye. Measurements of IPL effects were per-
formed within three places in the eye area: first place (B) two centimeters
in a straight line from the outer corner of the eye, second place (C) 2 cm
from the pupil on the lower eyelid and third place (D) 2 cm down from
the outer corner of the eye. Measurements in three places were due to
the fact that IPL treatment was not performed on upper eyelid.
The research project and its procedures were approved by the Bio-
ethics Committee of the Medical University of Lodz (Protocol No.
RNN/152/14/KE and No. RNN/97/15/KE).
3 | RESULTS
3.1 | Statistical analysis
Results are presented as a mean value and standard deviation (mean 6
SD). The significance of variations in the measured parameters: R7,
MEX, ERYT at each time point was analyzed with the use of repeated
measures of ANOVA with the Greenhouse-Geisser amendment and
post hoc test comparisons with Bonferroni’s amendment. Pearson’s
correlation was used to assess the correlation between the results
(Tables 1 and 2).
Descriptive findings are presented as simple portions [%] or means
and standard deviations (mean 6 SD). The normality of data distribution
was verified with the Shapiro-Wilk test, and variance homogeneity was
tested with Levene’s test. To estimate the significance of differences
between selected groups, one-way ANOVA with Tukey post hoc tests
or ANOVA with a Greenhouse-Geisser correction followed by post hoc
test using the Bonferroni correction (for repeated measures) were
applied. Qualitative data were analyzed with chi-square test or the
exact Fisher’s test where needed.
The results of cutometric measurement of R7 indicate improved
skin elasticity in case of all three methods of treatment. In case of frac-
tional, non-ablative laser and non-ablative RF, the highest statistically
significant improvement (p <.0001) was observed during the series of
treatments in the area within the upper (1/3 of the length of supercili-
ary arch) and the lower (2 cm from the pupil) eyelid. IPL treatment was
not performed on the upper eyelid, but statistically significant differen-
ces (p 5 .010) were found in case of the lower eyelid (2 cm from the
| 3 of 9
pupil). In case of fractional, non-ablative laser, non-ablative RF and IPL,
the smallest change in skin elasticity was observed for the site at outer
corner of eye (two centimeters in a straight line from the outer corner
of the eye) (p 5 .017, p 5 .003, and p 5 .001, respectively). Statistically
significant improvement (p < .0001) in skin elasticity at the top of the
cheekbones (2 cm down from the outer corner of the eye) was shown
in case of non-ablative RF and IPL. In case of non-ablative fractional
laser, the improvement was smaller: p 5 .005.
At the beginning, a significant increase in skin elasticity in analyzed
sites can be observed in case of all treatment methods during the series
of treatments, but then it decreases. Only in case of non-ablative RF,
the improvement in all three measured points is observed three
months after the last treatment. In all measured sites and in case of all
methods, the greatest improvement in skin elasticity was demonstrated
between the first and second measurement.
The results of mexametric measurement—MEX (melanin level) as
well as ERYT (severity of erythema) are statistically insignificant in case
of RF. In case of IPL, statistically significant results of MEX were
obtained in three measured sites: 1/3 of the length of superciliary arch
on the upper eyelid—p 5 .005, 2 cm in a straight line from the outer cor-
ner of the eye—p 5 .026 and 2 cm down from the outer corner of the
eye—p 5 .003. Results of ERYT measurement for IPL were not statisti-
cally significant. In case of fractional non-ablative laser, a statistically sig-
nificant change in skin color in both MEX and ERYT measurement was
seen. In all measured sites, the most significant changes were occurred
after the fourth and fifth series of treatment. The results of measure-
ments between the first and the fourth procedure were varied slightly.
Percentage change in values between measurement 1 (before the
series of treatment) and measurement 3 (results of measurement two
weeks after the fifth treatment) for three parameters R2, R6, and R7
was calculated as a part of statistical analysis. This comparison was per-
formed for the fourth place of measurement—2 cm down from the
outer corner of the eye. The highest statistically significant efficiency
[%] was observed in case of R6 parameter in case of fractional non-
ablative laser treatment. This treatment was associated with signifi-
cantly (p < .0001) better results in comparison to other methods. Other
comparisons were not statistically significant.
In case of [%] change in R2 values between the measurement 3
and 1, highest differences were observed for IPL, while the lowest for
RF. In case of [%] change in R7 values between the measurement 3
and 1, highest differences were observed for IPL. Statistically signifi-
cant change [%] in R6 values between the measurement 3 and 1 was
demonstrated in case of fractional non-ablative laser in comparison to
other methods.
After non-ablative fractional laser treatment, patients noticed: red-
ness, burning and swelling which subsided after approximately 6 hr.
Additionally, most of patients noted small scabs which remained visible
for no longer than 7 days. After non-ablative RF, most of patients had
only erythema which subsided within 1–3 hr. Following IPL treatment,
some patients observed redness, sometimes burning (visible up to 1 hr
after the treatment) and tenderness (visible up to approximately 3–12 hr
after the treatment). Some patient with hyperpigmentation perceived
4 of 9 | AUGUSTYNIAK AND ROTSZTEJN

TA BL E 1 R7 parameters according to site and time of measurement

R7 parameters according to site and time of measurement—non-ablative laser treatment

N 5 24 Measurement 1 (*) Measurement 2 (#) Measurement 3 (^) Measurement 4 Significance

1/3 of the length of superciliary arch on the upper eyelid

R7 0.252 6 0.135 **0.344 6 0.114 ***0.359 6 0.120 ***0.275 6 0.140^ p<.0001

2 cm in a straight line from the outer corner of the eye

R7 0.287 6 0.155 0.333 6 0.159 0.332 6 0.132 0.286 6 0.145 p 5 .017

2 cm from the pupil on the lower eyelid

R7 0.239 6 0.154 ***0.351 6 0.146 *0.302 6 0.155 #0.269 6 0.154 p<.0001

2 cm down from the outer corner of the eye

R7 0.176 6 0.118 **0.231 6 0.110 0.227 6 0.116 0.222 6 0.121 p 5 .005

R7 parameters according to site and time of measurement—non-ablative RF

N 5 23 Measurement 1 Measurement 2 Measurement 3 Measurement 4 Significance

1/3 of the length of superciliary arch on the upper eyelid

R7 0.135 6 0.042 ***0.200 6 0.048 *0.204 6 0.083 ***0.226 6 0.057 p<.0001

2 cm in a straight line from the outer corner of the eye

R7 0.145 6 0.061 0.166 6 0.067 *0.182 6 0.048 0.183 6 0.067 p 5 .003

2 cm from the pupil on the lower eyelid

R7 0.149 6 0.094 **0.204 6 0.089 **0.205 6 0.087 0.189 6 0.057 p<.0001

2 cm down from the outer corner of the eye

R7 0.134 6 0.061 **0.204 6 0.060 ***0.211 6 0.045 ***0.214 6 0.080 p<.0001

R7 parameters according to site and time of measurement—intense pulsed light

N 5 24 Measurement 1 (*) Measurement 2 (#) Measurement 3 (^) Measurement 4 Significance

2 cm in a straight line from the outer corner of the eye

R7 0.167 6 0.080 **0.218 6 0.070 **0.267 6 0.112 ^0.197 6 0.069 p 5 .001

2 cm from the pupil on the lower eyelid

R7 0.156 6 0.096 **0.201 6 0.072 *0.208 6 0.039 0.192 6 0.062 p 5 .010

2 cm down from the outer corner of the eye

R7 0.148 6 0.057 ***0.213 6 0.035 ***0.252 6 0.050# ***0.210 6 0.052^ p<.0001

The results are presented as mean 6 SD (standard deviation).

*p < 0.05; **p < 0.01; ***p < 0.001 vs. (in comparison to) 1st measurement.
#
p < 0.05 vs. 2nd measurement.
^p < 0.05 vs. 3rd measurement.

slightly darker color of pigmented lesions which persisted up to 7 days
after treatment.
4 | DISCUSSION
The aim of this study was to perform mexametric evaluation of pig-
mentation treatment results with the use of non-ablative laser, non-
ablative RF and IPL device. The results of mexametric measurements
of MEX in case of RF are statistically insignificant. In the case of IPL,
significant differences in MEX in three measured sites was observed:
p 5 .005 for 1/3 of the length of superciliary arch on the upper eye-
lid, p 5 .026 for a site 2 cm in a straight line from the outer corner of
the eye and p 5 .003 for a site 2 cm down from the outer corner of
the eye. Other authors used Mexameter to assess the reduction in
local hyperpigmentation of skin [Choi, Choi, et al., 2010; Jalaly, Vali-
zadeh, Barikbin, & Yousefi, 2014; Li et al., 2008; Park, Kim, et al.,
2011]. In our study, measurements were performed regardless of
the presence of skin discoloration, at fixed locations for both the
measurement with Cutometer and Mexameter probe. In Li YH et al.
study, eighty-nine women with melasma underwent four sessions of
IPL treatment. Mexameter results demonstrated a significant
decrease of pigmentation and erythema beneath the melasma
lesions (Li et al., 2008). Shin JW et al. used Mexameter as an objec-
tive and non-invasive tool of the evaluation of photorejuvenation
effect with IPL treatment of the skin of 26 women. Measurement
demonstrated significant improvements following IPL treatments
that were most remarkable after one session of IPL (Shin et al.,
2011). Wanitphakdeedecha R et al. assessed the improvement in
melasma and side effects after 1,410 nm fractional photothermolysis
AUGUSTYNIAK AND ROTSZTEJN | 5 of 9

TA BL E 2 MEX and ERYT parameters according to site and time of measurement

MEX and ERYT parameters according to site and time of measurement—non-ablative laser treatment
Measurement Measurement Measurement Measurement Measurement Measurement
N 5 26 1 (*) 2 (#) 3 (^) 4 (@) 5 ($) 6 Significance

1/3 of the length of superciliary arch on the upper eyelid

MEX 153.3 6 37.6 159.2 6 35.7 155.7 6 39.1 155.3 6 25.8 158.3 6 39.3 162.4 6 35.6 NS (p5.224)
ERYT 317.9 6 72.3 314.2 6 79.8 323.2 6 79.8 330.1 6 80.3 334.4 6 82.9 336.6 6 78.7 NS (0.090)

2 cm in a straight line from the outer corner of the eye

MEX 160.6 6 41.4 168.7 6 42.1 161.1 6 39.9 169.9 6 41.4 ^175.6 6 41.9 ***188.6 6 42.8 p<.0001
###^@@@$
ERYT 324.2 6 109.0 335.4 6 89.4 342.2 6 91.1 346.7 6 81.2 358.8 6 98.2 *362.5 6 87.7 p5.001

2 cm from the pupil on the lower eyelid

MEX 141.4 6 39.6 145.8 6 46.6 142.2 6 40.0 141.2 6 47.9 155.1 6 44.2 **161.6 6 44.7^@@ p<.0001
ERYT 397.2 6 98.3 389.5 6 91.4 406.4 6 103.1 408.0 6 110.9 ##433.0 6 97.0 *##432.9 6 100.4 p5.001

2 cm down from the outer corner of the eye

MEX 141.0 6 40.3 147.1 6 36.0 146.1 6 38.2 147.3 6 44.7 158.1 6 39.5 **##165.2 6 38.6^@@ p<.0001
ERYT 341.9 6 98.3 329.5 6 81.7 352.2 6 85.0 ##371.7 6 86.2 ##**384.8 6 84.7^ **394.3 6 91.1###^ p<.0001

Data presented as mean6SD.

*p<0.05; **p<0.01; ***p<0.0001 vs measurement 1.
##
p<0.01; ###p<0.0001 vs measurement 2.
Ù
p<0.05; ÙÙp<0.01; ÙÙÙp<0.0001 vs measurement 3.
@@
p<0.01; @@@p<0.0001 vs measurement 4.
$
p<0.05 vs measurement 5.
NS - not significant; MEX - xxxx; ERYT - xxx.

MEX and ERYT parameters according to site and time of measurement—non-ablative RF

N521 Measurement 1 Measurement 2 Measurement 3 Measurement 4 Measurement 5 Measurement 5 Significance

1/3 length of superciliary arch on the upper eyelid

MEX 161.9 6 35.6 168.6 6 35.8 165.0 6 35.8 162.4 6 38.9 165.5 6 40.5 157.8 6 27.5 NS (0.487)
ERYT 317.8 6 61.4 316.2 6 74.3 309.9 6 59.4 308.6 6 57.6 307.4 6 55.8 327.4 6 67.4 NS (0.347)

2 cm in a straight line from the outer corner of the eye

MEX 176.1 6 39.9 184.8 6 48.2 182.0 6 44.1 174.5 6 41.7 173.6 6 36.3 172.1 6 32.1 NS (0.191)
ERYT 317.2 6 81.2 333.7 6 88.7 310.8 6 83.7 329.2 6 88.6 324.2 6 84.8 323.3 6 84.4 NS (0.399)

2 cm from the pupil on the lower eyelid

MEX 161.6 6 36.2 167.3 6 43.3 161.7 6 40.5 158.1 6 41.8 154.4 6 32.1 157.1 6 37.0 NS (0.439)
ERYT 396.9 6 97.6 392.2 6 96.0 410.6 6 104.9 401.5 6 95.7 393.1 6 85.0 395.9 6 93.0 NS (0.700)

2 cm down from the outer corner of the eye

MEX 158.3 6 43.0 162.4 6 44.4 160.0 6 39.9 150.8 6 32.8 161.1 6 33.7 153.8 6 35.4 NS (0.226)
ERYT 343.4 6 89.9 349.4 6 80.3 344.3 6 99.6 349.4 6 89.1 343.6 6 89.4 352.6 6 97.4 NS (0.921)

Data presented as mean±SD.

NS - not significant; MEX - xxxx; ERYT - xxx.

MEX and ERYT parameters according to site and time of measurement—intense pulsed light
N523 Measurement 1 (*) Measurement 2 (#) Measurement 3 (^) Measurement 4 (@) Measurement 5 ($) Measurement 5 Significance

1/3 length of superciliary arch on the upper eyelid

MEX 160.4 6 26.8 157.7 6 27.2 149.1 6 26.6 146.2 6 29.9 **134.8 6 17.3## $151.5 6 24.3 p5.005
ERYT 289.9 6 80.4 292.4 6 77.5 294.2 6 80.8 274.3 6 63.3 276.4 6 72.0 310.8 6 79.6 NS (0.057)

2 cm in a straight line from the outer corner of the eye

MEX 140.1 6 29.2 133.8 6 26.6 133.6 6 25.9 137.8 6 20.6 141.4 6 22.8 143.3 6 27.1 p5.026
ERYT 285.8 6 84.9 303.4 6 85.2 291.2 6 79.6 279.7 6 82.9 274.4 6 74.1 292.9 6 86.8 NS (0.080)

2 cm from the pupil on the lower eyelid

MEX 135.2 6 28.5 127.4 6 24.7 128.5 6 28.2 127.7 6 27.7 134.8 6 28.4 134.7 6 28.4 NS (0.083)
ERYT 391.4 6 83.9 393.5 6 95.5 381.7 6 91.4 373.0 6 96.6 384.8 6 86.5 401.3 6 88.5 NS (0.351)
(continues)
6 of 9 | AUGUSTYNIAK
TA BL E 2 (continued)
MEX and ERYT parameters according to site and time of measurement—intense pulsed light
N523 Measurement 1 (*) Measurement 2 (#) Measurement 3 (^)
2 cm down from the outer corner of the eye
MEX 129.8 6 24.2 129.1 6 24.1 127.9 6 26.5
ERYT 314.8 6 78.9 318.6 6 76.7 307.4 6 60.5
Data presented as mean6SD.
**p<0.01 vs measurement 1.
##
p<0.01 vs measurement 2.
@
p<0.05 vs measurement 4.
$
p<0.05 vs measurement 5.
NS - not significant; MEX - xxxx; ERYT - xxx.
laser treatments. Thirty patients were treated monthly for five times.
They underwent random treatment of the whole face: one side with
20 mJ at 5% coverage and the other side with 20 mJ at 20% cover-
age. In this study patients’ satisfaction was significantly higher on
the side treated with 20 mJ, 5% coverage. Moreover, there was not
statistically significant improvement of Melanin index at 1-month
follow-up visit but it was observed during 2- and 3-month follow-up
visits (Wanitphakdeedecha, Keoprasom, Eimpunth, & Manuskiatti,
2014). In our study, mexametric examinations were completed two
weeks after the last treatment.
The 1,410 nm non-ablative fractional laser, which was used in our
study, is claimed to cause coagulation of 2.5% of the scanned skin
area. The columns of coagulation did not reach 450 microns into the
dermis. The parameters were selected individually depending on
patient’s Fitzpatrick’s phototype to reduce the risk of post-treatment
discoloration and conversely, to decrease the existing ones. Thus, in
patients with darker phototype and with skin with visible discolorations
lower energy density (mJ/lC), concentration pattern and the number
of micro columns in a scanning surface were used. For example: for
patients with medium and dark phototype III and light phototype IV:
energy beam of 20 mJ/lC, concentration pattern 8 3 5, the number of
micro columns in scanning surface unit—40, the distance between the
micro columns—1.5 mm. Wanitphakdeedecha R et al. stated that treat-
ment parameters can be set at pulse energy ranging from 5 to 20 mJ
and treatment level ranging from 5% to 20% coverage. To optimize the
treatment outcome in patients with pigmented lesions, mild to moder-
ate photodamage melasma and dyschromia, 1,410 nm fractional laser
photothermolysis has been released (Wanitphakdeedecha, Keoprasom,
et al., 2014). In our study, mexametric measurements demonstrated a
statistically significant change in skin color toward the intensification of
pigmentation, which was observed in case of both MEX and ERYT. In
all sites in which measurements were made, the most significant
changes occurred after the fourth and fifth session of treatment. The
results obtained between the first and the fourth procedure varied
insignificantly. Despite the use of sun protection, patients in Poland
were exposed to stronger sunlight during spring months (April/May),
which could affect the severity of skin pigmentation. Conversely, it
may be associated with post-inflammatory hyperpigmentation, which
AND ROTSZTEJN
Measurement 4 (@) Measurement 5 ($) Measurement 5 Significance
127.5 6 24.0 131.0 6 22.0 @138.5 6 25.9 p5.003
297.4 6 83.7 303.1 6 71.0 325.8 6 73.3 NS (0.090)
frequently occurs in darker-skinned individuals (Tanzi, Wanitphakdee-
decha, & Alster, 2008). The treatment of hyperpigmentation is difficult
due to the risk of post-inflammatory pigmentation changes following
treatment procedures (Wanitphakdeedecha, Manuskiatti, Siriphuk-
phong, & Chen, 2009). Kono et al. compared the efficacy and complica-
tions of the use 1,410 nm non-ablative fractional laser with different
density and fluencies settings. According to him, the use of increased
density was associated with higher risk of adverse effects in compari-
son to increased energy. Moreover, patient’s satisfaction was signifi-
cantly higher after the treatment with high fluencies, but not with high
densities (Kono et al., 2007). In our study, the comparison between var-
ious fluencies and densities was not performed since we assumed that
the use of lower density in patients with higher phototypes is recom-
mended to avoid possible complications.
QY Park et al. compared the efficacy and safety of a non-ablative,
595-nm pulsed dye laser (PDL) and 1,550-nm fractional laser in the
treatment of acne erythema. The effectiveness was assessed on the
basis of a mean change in investigator’s and patients’ clinical evaluation
and mexameter scores. QY Park et al. suggested that physicians pre-
ferred the non-ablative 1,550-nm fractional laser for the treatment of
acne erythema (Park, Ko, Seo, & Hong, 2014). Wang B et al. found that
the IPL treatment reduced skin redness by about 10% and skin pigmen-
tation by about 17%. They evaluated the efficacy of the combination
of IPL and fractional CO2 laser in the treatment of 37 patients with
acne and both scarring and inflammatory lesions. Effectiveness was
determined on the basis of patient self-assessment, dermatologist’s
evaluation and Mexameter (Wang et al., 2013). In our study, the results
of ERYT for IPL and RF were statistically insignificant.
Moody et al. in their study demonstrated that 1,550-nm fiber laser,
besides the reduction of discoloration, also had beneficial impact on
skin aging since such symptoms became less visible following the treat-
ment (Moody, Landau, Goldberg, & Friedman, 2012). Skin elasticity
was not visible as it is in the case of wrinkles reduction (Figure 1).
Therefore, Cutometric measurements provided invaluable help in the
objective evaluation of the anti-aging treatment. R7 parameter is one
of the most common Cutometric parameter used in medical literature
to assess skin aging. In Krueger et al. study involving 120 healthy
women, the biomechanical properties of the skin were measured using
AUGUSTYNIAK AND ROTSZTEJN | 7 of 9

F I G U R E 1 Patient AB, age 35 before the first treatment non-ablative, fractional laser session after the last one. Patient CD, age 49, before
the first session of treatment with non-ablative RF and after the last one. Patient EF, age 47, before the first session of treatment with
intense pulsed light session and after the last one [Color figure can be viewed at wileyonlinelibrary.com]

the Cutometer on cheek, neck, cleavage, volar forearm and back of the
hand. The ratio of elastic recovery to distensibility (Ur/Uf) as well as the
gross elasticity (Ua/Uf) had a high correlation with age. It seems that R7
parameter is most suitable indicator of the influence of aging on
mechanical properties of the skin (Krueger et al., 2011). Choi et al. ana-
lyzed the skin of 97 females with the use of Cutometer, Corneometer,
and Visioscan probes. The aim of their study was to assess the objec-
tive relationship between age, the presence of wrinkles, skin viscoelas-
ticity and hydration level. According to authors, elastic recovery ratio
(R7) decreased with age along with the decline of elastic fibers.
Increased elastase activity and negative effects of ultraviolet radiation
on elastic fibers explains why older people have lower R7 values (Choi,
Kwon, et al., 2013). Studies conducted by other researchers confirm
the results of R7 analysis obtained by Choi JW [Ahn et al., 2007;
Krueger et al., 2011; Ryu et al., 2008; Takema, Yorimoto, Kawai, Imo-
kawa, 1994]. Our study results are also in agreement with the above
mentioned statements. Statistical analysis of our results concerning R7
parameter, revealed that series of non-ablative laser, non-ablative RF
and IPL treatments are associated with the improvement of skin elas-
ticity. The highest statistically significant improvement (p < .0001) was
observed within sites on the upper (1/3 of the length of superciliary
arch) and lower eyelid (2 cm from the pupil) in case of fractional non-
ablative laser and non-ablative RF during the treatment. The skin of
the upper eyelid was characterized by higher improvement in elasticity
than the skin of the eye corner (two centimeters in a straight line from
the outer corner of the eye). Statistically significant improvement
(p < .0001) in skin elasticity after non-ablative RF and IPL was observed
also at the top of cheekbones (2 cm down from the outer corner of the
eye) showed. In case of a non-ablative fractional laser the improvement
was a bit less visible (p 5 .005). The presence of wrinkles, which
8 of 9 | AUGUSTYNIAK
influence skin deformation within Cutometer measuring probe, could
affect the results of measurements at various points. Moreover, in all
sites of measurement and in case of all treatment methods, the great-
est improvement in skin elasticity was observed between the first and
second measurement. Subsequent treatment sessions were associated
with much slower rate of changes. Only in case of non-ablative RF, the
improvement within three sites was seen after three months from the
last treatment, which may suggest that in a thermally modified skin the
remodeling process is most intensified as a result of early stimulation.
In our study, most significant differences were observed for R6 param-
eter. R6 determines viscoelasticity which is often associated with skin
hydration. This might indicate a decrease in viscosity of interstitial fluid
as a result of increased water level and changes in composition and/or
structure of proteoglycans (Kapoor & Saraf, 2010). A relationship
between skin moisture and R6 parameter was confirmed by other
authors (Dobrev, 2000; Pierard, Nikkels-Tassoudji, & Pierard-
Franchimont, 1995; Wickett, 2001). On basis of aforementioned
results, it can be stated that fractional non-ablative laser influences
extracellular matrix remodeling to a greatest extent in comparison to
other methods.
5 | CONCLUSION
Cutometer seems to be an effective method of the assessment of flexi-
bility while Mexameter – the method of the assessment of skin pig-
mentation and redness after treatment in the field of cosmetology.
Fractional non-ablative laser, non-ablative RF, and IPL can be consid-
ered as methods significantly affecting skin elasticity and to a lesser
extent influencing erythema and skin pigmentation. These procedures
are well tolerated and are associated with a low risk of side effects.
ACKNOWLEDG MENTS
This study was supported by statutory research activity Department
of Cosmetology and Aesthetic Dermatology, Faculty of Pharmacy,
Medical University of Lodz no.: 503/3-066-01/503-31-001 and
502-03/3-066-01/502-34-059.
CONFLIC T OF I NTE R ES T
The authors report no conflict of interest. The authors themselves
are responsible for the content and writing of the paper.
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