Fox eyes lift—A new protocol for eyebrow elevation with laser Fotona

The eyelids play an important role in our appearance and are usually the first to show signs of age. The Fotona SP Spectro Systems consist of a range of noninvasive laser treatments that work together synergistically to tighten the collagen in four dimensions and provide long‐lasting firmness to the face. The Fotona SP Spectro combines two wavelengths: Er:YAG (2940 nm) and Nd:YAG (1064 nm) with four distinct treatments: SmoothLiftingTM, FRAC3®, PIANO®, and SupErficialTM, allowing safe, painless, noninvasive, and no downtime rejuvenation.

minimal downtime.Nonsurgical procedures have become the first treatment option for many patients since they permit a quick return to regular activity.There are several rejuvenating treatments for the periocular region, including chemical peels, laser resurfacing, PDO threads, hyaluronic acid fillers, and, more recently, several energy-based devices.Recent developments in aesthetic and laser medicine, combined with anatomical considerations and patient preferences for procedures with minimal downtime, have altered treatment trends.However, some of these treatments may lead to unwanted side effects such as dyspigmentation, pain, or a prolonged recovery period. 2,3elid rejuvenation through the use of Er:YAG lasers has been demonstrated as an effective and reliable method. 4,5The Er:YAG laser is a nonablative treatment with a lower risk of complications and usually without downtime. 6,7The Nd:Yag laser have low absorption of skin chromophores such as melanin, deoxyhemoglobin, and oxyhemoglobin, then, the energy is only minimally lost during penetration into the deeper layers of the skin, where the target elements such as veins and hair bulbs are located.Low competition with the skin's chromophores helps to preserve the epidermis from hypo-and hyper-pigmentation, being of extreme importance when treating skins of phototype III or greater.
Fotona4D® is a comprehensive facial antiaging treatment that involves four different procedures using Fotona's SP Dynamis or SP Spectro systems: SmoothLiftinTM, FRAC3®, PIANO®, and Su-pErficialTM.When used together, these treatments can effectively combat facial aging with minimal downtime and can be performed year-round.The SmoothLiftingTM is a nonablative Er:YAG intraoral procedure that utilizes controlled and gentle bulk heating to stimulate collagen contraction.This results in an overall improvement of tightness and elasticity in the treated tissue, as well as a plumping effect on the nasolabial folds.FRAC3® is a self-induced, fractional effect of the Nd:YAG laser and a specific pulse structure that generates tiny regional spikes of high temperature, inducing a three-dimensional fractional microdamage pattern in the skin, stimulating the formation of new collagen and elastic fibers, resulting in the restoration of a more youthful texture.This is particularly effective in treating deeper imperfections within the skin. 8In the third stage of Fotona4D®, PIANO® utilizes an ultra-long Nd:YAG pulse mode to safely and quickly induce bulk tissue heating from the outside in, concentrating energy delivery subcutaneously promoting an tightening effect.Additionally, SupErficialTM enhances the skin's appearance and reduces imperfections by utilizing proprietary VSP technology, which allows for precise adjustments of the laser to achieve a controlled light peel without any thermal effects, resulting in a no downtime and highly accurate treatment.
The SMOOTH® mode is a nonablative treatment that delivers optical energy to the skin in a controlled manner, without causing bleeding and with precise temperature control.This is achieved through a unique subsecond pulse sequence that prevents temperature buildup on the surface of the skin and promotes homogeneous heating of the tissue up to several hundred micrometers deep.The SmoothEye® (SE) is a nonablative Fotona SMOOTH® mode treatment for tightening of the periocular region and reducing the appearance of periorbital wrinkles, reducing the loose and aging skin of the eyelids and periocular region with little-to-no downtime.
Procedures using SMOOTH® mode Er:YAG laser pulse sequences from Fotona laser have recently shown excellent clinical results.These procedures are characterized by moderate cumulative fluences that are not only below the ablation threshold but also below the patient's pain threshold, making them comfortable for patients. 9,10The SMOOTH mode Er:YAG laser energy has been found to induce changes in the deeper skin or mucosa, initiating a process of cell activation, production of extracellular matrix, and tissue remodeling, without causing unwanted direct epithelial ablation. 8The Er:YAG SMOOTH mode can be applied to the surface of the skin and also via the transconjunctival route approach to stimulate collagen remodeling and contraction.The skin tightening effect of SMOOTH applied to the frontotemporal region has been associated with mild eyebrow elevation.We have developed a new protocol aiming to increase tightening in the periocular area in order to improve brow elevation.
Fox eyes lift (FEL) is a combination of Er:YAG and Nd:Yag modes, unlike the SE that uses only the Er:Yag to rejuvenate the periocular region.The present study suggests an innovative and safe technique for eyelid and eyebrow rejuvenation using the Fotona SP Spectro.

| MATERIAL S AND ME THODS
This is an interventional, split-face, comparative study approved by the local Ethics Committee and according to the Helsinki Statement.
All patients gave written informed consent to participate in this research including the images presented in the study.The sample consisted of 21 subjects (19 women) with a mean age of 50.1 ± 7.9 years who underwent nonablative laser-assisted eyebrow lift with Fotona SP Spectro.The therapeutic planning included three sessions over a 3-month period.We apply a topical anesthetic ointment 15 min before the procedure and remove it with an aqueous chlorhexidine solution.Patients did not receive any skin preparation and did not undergo herpes prophylaxis.After the procedure, we recommend using a topical moisturizer three times a day for 1 week in combination with sunscreen.
The SE protocol, which is the standard protocol, involves the use of Fotona SMOOTH®, a superlong nonablative mode of Er:YAG laser.
This mode gently heats the skin without causing significant ablation of the superficial layers.During the treatment, the patient received Er:YAG SMOOTH mode using a PS03 handpiece with a spot size of 7 mm and a fluence of 3.5 J/cm 2 .Each spot received 3-4 pulse trains.
The treatment involved two passes in two rows above the eye, three passes below the eye, and three passes lateral to the eye.The number of rows usually depends on the individual's anatomy.The SE protocol does not include laser application to the frontotemporal region.
The FEL protocol, proposed by the study, includes the following steps (Figure 1): 1-Nd:Yag 1064 nm FRAC3® fluency 10 a 25 J applied to the lower eyelid and to a lateral portion of the frontal area; 2-2940 nm Er:Yag laser Fotona Smooth PS02 handpiece, applied in circular movements to the upper and lower eyelids and to the lateral portion of the frontal region using a fluence of 3-4 J/cm 2 , a repetition rate of 2 Hz, and ten complete passes; 3-2940 nm Er:Yag laser Fotona Smooth PS03 handpiece, applied to the upper and lower eyelids, medial corner, lateral corner, outer half of the frontal region, invading the hairline, using a fluence of 3-4 J/cm 2 , a repetition rate of 2 Hz, and three complete passes (see Video S1).
The FEL protocol differs from the standard protocol as it uses two wavelengths (Er:YAG and Nd:YAG) compared to the single wavelength used in the SE protocol (Er:YAG only).Additionally, the FEL protocol involves more passes with the Er:YAG wavelength and also utilizes multiple tips to enhance the results.Another important point to note is that the FEL protocol also differs in terms of the application site, as in this technique, the laser is applied to the eyelid and frontal regions, unlike the SE protocol, which only uses the laser in the periorbital area.test.The effect size reported was the generalized Squared Eta, (η 2 g), being considered small (0.2), medium (0.5), or large (0.8). 11 All procedures were performed using R Software (version 4.1.1,R Core Team, Vienna, Austria).

| RE SULTS
Both protocols were efficient in elevating the eyebrow, as shown in  One patient reported swelling and redness of the eyelids with slight skin peeling on both sides, although with greater edema and redness on the side treated with the FEL protocol (Figure 4).We observed a highly significant asymmetry in two patients, with the side treated with the FEL protocol raising the eyebrow much more than the side treated with SE, a fact causing aesthetic discomfort for these patients (Figure 5).After completing the study, these two patients were submitted to three additional Fotona sessions with reversal of the protocol used, and the asymmetry was resolved.One patient did not see improvement with treatment (although objective data did document improvement), while all the others observed improvement in eyelid opening, brow lift, wrinkle reduction, and skin quality.Most patients observed a higher brow position with the FEL protocol (15 patients), but did not complain about the difference in height of the eyebrows (Figures 6,7) and five patients found that both eyes improved.

| DISCUSS ION
A highly desirable method of eyelid rejuvenation would be one that combines efficacy with no downtime and minimizes the risk of unwanted side effects.Between 2010 and 2012, Gansel RW et al.
conducted a study on over 100 patients using the FRAC3® skin tightening procedure, which revealed that this modality is highly promising in terms of achieving effective results with minimal risk of side effects.Good to excellent procedure satisfaction rates were reported by over 90% of the patients treated. 12study published by Song et al. showed that 1064 nm laser alone significantly improved skin texture, spore, brown spots, elasticity, and melanin compared to baseline (p < 0.5), and the 2940 nm laser alone showed significant improvements on wrinkle, texture, pore, and elasticity rates (p < 0.5).The combined treatments showed significant improvements on the above mentioned indexes compared to either 1064 nm or 2940 nm laser treatment alone (p < 0.5). 13 addition to skin tightening, FRAC3® therapy can cause permanent hair removal, which can be a problem in certain anatomical regions of men, such as the beard region.This has to be considered since it can also be regarded as an unwanted side effect in certain other anatomical regions of male patients, for example.We also observed a reduction in telangiectatic vessels and skin sun damage.When treating conditions such as wrinkles, combining the FRAC3® method with an Er:YAG laser treatment may result in enhanced skin tightening. 12e use of nonablative long-pulse 2940 nm Er:YAG laser and FRAC3® is becoming increasingly popular for enhancing the structure, function, and appearance of periorbital skin.The present study showed that combining these two lasers, that is, long-pulse 2940 nm Er:YAG laser and FRAC3® Nd:YAG laser, was safe and that the efficacy of treatment was superior regarding skin laxity and brow lift. 13rthermore, a recent investigation demonstrated a possible method for lower eyelid tightening using nonablative Er:YAG SMOOTH™ mode with a transconjunctival approach in 30 patients.The authors performed three sessions of Fotona laser application at 15-day intervals, and the result was evaluated by an independent investigator using a high-resolution photograph taken 30 days after the last laser session.Following the third session, the degree of improvement was evaluated as very significant in 14% of patients (four patients), marked in 30% (nine patients), moderate in 43% (13 patients), minor in 10% (three patients), and no improvement in 3% (one patient). 14nchaprateep R conducted a study that found a combination of cases without any serious complications. 15Merick G reported reduction in deep lines and wrinkles around the eyes using the Fotona SP Dynamis system with Er:YAG and Nd:YAG crystals, additionally stimulating collagen production to sustain the results of treatment and visibly reducing skin aging. 16her minimally invasive technologies with minimal or no downtime such as microfocused ultrasound and microneedled radiofrequency have been described in the literature, promoting rejuvenation of the periocular region with elevation of the eyebrow tail.Microfocused ultrasound (MFU) produces zones of thermal injury and is used for the treatment of various age-related changes, including lower eyelid fat bulge and sagging of the eyelids and eyebrows.It is a safe and effective rejuvenation alternative, but it requires deep anatomical knowledge and effective training with the equipment. 17MFU devices use ultrasonic energy at a frequency of 4-7 MHz to create spaced, discrete zones of thermal microcoagulation in defined tissue planes within the dermis and hypodermis, which can provide a nonsurgical brow lift.The targeted delivery of thermal energy to particular tissue planes within the dermis and hypodermis results in collagen contraction, leading to an upward and inward lifting effect and promoting neocollagenesis. 14vel of Evidence II studies have quantified the lift effect, demonstrating that 89% of subjects achieved clinically significant brow lift 90 days after a single treatment session, with a mean lift of 1.7 mm. 18e process of microneedle fractionated bipolar RF entails utilizing a microneedle array to deliver RF energy directly to the reticular dermis.When used for midface volumetric rejuvenation, this treatment can result in a positive effect of periorbital structure being outwardly and upwardly vectored.The continuous use of monopolar RF can also be used to rejuvenate the eyebrows and eyelids through subdermal heating. 2 Other technologies used for eyelid rejuvenation such as CO 2 laser and jet plasma involve greater discomfort at the time of application and have greater downtime.
The SE protocol uses only the Erbium Yag from the Fotona laser with the PS03 handpiece applied only to the upper and lower eyelids and lateral and medial corners.Although this protocol treats only one skin layer, it promotes a significant improvement in eyelid retraction and a slight brow lift.The FEL protocol uses the two lasers available at Fotona, ND Yag, and Er Yag, the latter requiring two handpieces, PS02 and PS03, applied more comprehensively than in the SE protocol, since it is also applied to the frontal region.Besides, this protocol reaches a greater number of skin layers, activating greater collagen production in multiple layers and consequently having a greater lifting effect on the eyebrow.
The limitations of noninvasive procedures regarding eyebrow elevation are already known, and this technology certainly contributes to rejuvenating this area and reducing the tired appearance.This study showed that the SE and FEL protocols promote a discreet elevation of the eyebrow, with FEL being superior as it works on more layers and utilizes two different wavelengths.One aspect to be evaluated in future studies is the combination of techniques according to the patient's sagging, anatomy, and age in order to achieve more significant results.
The application of FEL is very comfortable, the downtime is minimal, and the level of satisfaction is high.We suggest three sessions, F I G U R E 7 Some cases before and after treatment, being FEL in the left side and SE in the right side.TOP = before; BOTTOM = after.
Each patient received SE protocol which is the pattern on one side of the face, and FEL, proposed by the study, on the other.The technique used on each side was selected by drawing lots on the day of the first treatment.Three treatments were performed at 4 weeks' intervals.Photographic documentation was obtained with an iPhone 11 in the same setting, under the same light conditions and at the same distance.The head position was secured by the slit lamp head support.A total of two photographs were taken for each patient, before and 1 month after completing the treatment.The digital images were transferred to a computer and linear measures were performed with the NIH ImageJ public domain software (available for free download at https://imagej.nih.gov/ij/).Eyebrow position was measured from the eyelid lateral canthus vertically to the upper eyebrow before and after completing the treatment.(Figure 2).Categorical data are reported as frequency and percentage and continuous data as mean, standard error, and 95% confidence interval.A Repeated Measurements Factorial Analysis of Variance (ANOVA-MR) was performed to compare eyebrow position for Time (Pre vs. Post) and Technique (SE vs. FEL), as well as the interaction between these two factors (time and technique).Post hoc analysis was carried out by the Tukey-HSD (honestly significant difference)

Figure 3 (
Figure 3 (SE p = 0.0002 and FEL p < 0.0001).According to the statistical analysis, there was a mean elevation of the tail of the eyebrow of 1.75 mm (1.37-2.14;CI 95%) in FEL and 0.78 mm (0.48-1.07;CI 95%) in SE.ANOVA found difference between groups in the postprocedure (p = 0.0163) and showed that both protocols had a significant effect between Pre and Post times (F = 110.3;p < 0.0001; η 2 g = 0.030), as well as interaction between the Technique*Time factors (F = 19.0;p = 0.0003; η 2 g = 0.005).Tukey-HSD post hoc analysis identified a difference between SE versus FEL at Post procedure (p = 0.0163) and showed that the FEL protocol caused significantly greater post-pre differences (p = 0.0003, d = 0.95).
three different modes of Er:YAG (2940-nm) laser and Nd:YAG (1064nm) laser for treating lower eyelid bags was effective in 51.05% of F I G U R E 3 Elevation of the eyebrow with both techniques before and after full treatment (95% confidence interval).F I G U R E 4 Temporary eyelid redness and swelling after the treatment.F I G U R E 5 Important asymmetry in two patients, with the eyebrow higher on the side treated with the FE Lift Protocol.UP = before; BOTTOM = after.F I G U R E 6 Some cases before and after treatment, being FEL in the right side and SE in the left side.TOP = before BOTTOM = after.| 455 BURMANN et al.