In considering laser skin treatments, the layperson is confronted by marketing hyperbole that is part and parcel of the business of cosmetic surgery.
Not all lasers are created equal
Anyone considering laser resurfacing needs to have a basic understanding of the different types of laser treatments available today, their pros and cons, and alternative treatments. The price of not having this knowledge is that you may end up having a treatment of questionable value in this "buyer beware" environment. This is particularly true of treatments that advertise minimal recovery and "no downtime." A "healthy skepticism" is, quite literally, your best defense.
The "Ultrapulse®" laser was introduced to me in 1995. Pioneering physicians, plastic surgeons and dermatologists, had started using lasers to "resurface" the skin. Although lasers had been used in medicine and surgery for a few decades, they were too powerful to use on surface wrinkles. The aptly named "Ultrapulse® laser" was adapted so that it would fire very short bursts of energy, enough to vaporize the surface layers without harming the deeper skin cells. Although I greeted laser treatment with a degree of skepticism (wondering if the use of lasers on wrinkles was a more for marketing than for getting results), the theory seemed reasonable and I looked forward to seeing how it would work in practice.
Shortly after treating my first patient, I realized that this treatment offered a safe, effective treatment for wrinkles and skin blemishes that could be done at the same time as other procedures such as blepharoplasties and facelifts, to produce an overall facial rejuvenation. I started cautiously, doing a single "pass" or two with the laser, thinking that I could always do more (and wishing to avoid any complications).In fact, this conservative approach remains unchanged in my practice today.
The CO2 "Ultrapulse®" Laser Controversy
Some physicians pushed the limits and soon negative results were being reported by the media.
Unfortunately, over-treatment by some operators resulted in the following problems:
- The treated area had excessive redness that took months to fade
- In severe cases, patients developed scarring.
- Skin lightening ("hypopigmentation") was much more common than expected, producing conspicuous demarcation borders along the jawline.
These complications were typically caused by overaggressive laser treatment, and by the tendency of
CO2 lasers to produce hypopigmentation, which was under-recognized at first. Some surgeons returned to the older treatments such as dermabrasion and chemical peels that they had learned from their predecessors. The pendulum had swung back.
The Erbium: YAG laser was introduced in about 1997 and this laser offered a more superficial vaporization, a sort of "CO2 light."
A little basic physics and biology: Both the CO2 and erbium lasers produce wavelengths of light that are absorbed by water contained in skin cells. The erbium laser has a shorter wavelength which is absorbed much more readily by water in the surface skin cells than the CO2 laser. The top skin cells are vaporized with very little heat transmission to the deeper layers. With typical energy settings, each pass with the erbium laser vaporizes about 10 micrometers into the skin, barely penetrating the skin at all, versus 20-60 micrometers for each pass of the CO2 laser. More importantly, the heat that is transmitted deeper into the skin is much more superficial for the erbium laser - about 15 micrometers for the erbium laser versus 150 micrometers for the CO2 laser, a ten-fold difference! Not surprisingly, recovery times were found to be much faster after erbium laser resurfacing. The skin was healed in five days rather than a week. Redness faded in a few weeks rather than a few months.
At first, it appeared that the erbium laser might replace the CO2 laser because of the faster healing and shorter recovery time. However, precisely because there is less thermal effect on the deeper dermal layers of the skin, there is less collagen shrinkage and therefore less skin tightening and wrinkle improvement. The CO2 laser is not obsolete after all.
For over a decade now, the erbium laser and the judicious use of the CO2 laser have allowed me to obtain results not previously possible. I tend to use the erbium laser in younger patients and those with darker skin coloring. Patients of color and younger people tend to have less severe wrinkles. Undesirable pigment changes are avoided.
White people tend to wrinkle more. Because there is less melanin in the skin, there is less risk of hyperpigmentation. In older Caucasians, both lasers may be used to take advantage of the advantages of each laser. The CO2 laser is used for the deeper lines around the mouth, crow's feet, and lower forehead. The erbium laser is used to treat the less-wrinkled cheeks. This combination avoids the unwelcome demarcation line that a CO2 laser can leave along the jawline.
"Non-ablative" lasers were introduced to stimulate underlying collagen without removing ("ablating") the skin surface, thereby avoiding oozing and speeding recovery. This is a laudable goal. However, I've tried some of them and the results are underwhelming. It doesn't matter if the recovery is quick if the treatment does not work. Because of the apparent lack of effectiveness, non-ablative lasers didn't catch on. As it turned out, no amount of marketing claims can compensate for mediocre results.
Similarly, "fractionated" laser treatments attempt to achieve the results of an ablative laser treatment without the recovery time. The laser makes uniform patterns of tiny holes in the skin, preserving bridges of untreated skin between the holes. The energy is transmitted to the deeper skin layers, where the collagen may be heated, causing tightening but preserving intervening skin. This is an attempt to have our cake (skin tightening) and eat it too (minimal recovery).
Despite an intriguing concept, that looks great on the drawing board, the original "Fraxel® (fractionated laser) treatments did not seem to be very effective, probably due to inadequate heating of the deep layers. Perhaps the fractionated concept was the right idea, but not the right wavelength. The fractionated CO2 laser provides greater heating of the tissues ("thermal coagulation") and is a more promising idea that is presently being evaluated.
Making a Decision about Laser Treatments
Many patients are willing to accept a reasonable "down time" provided they get results. This is particularly true for patients who are having other procedures such as blepharoplasties (eye lid rejuvenation) or facelifts, who have prepared to be off work for a couple of weeks anyway.
- A litmus test for incorporation of a technique in my practice is that I have to be able to tell the "before" pictures from the "after" pictures. It is not rewarding for the physician or the patient for the post-procedure reaction to be: "I don't see a difference." You'd think this would be obvious, but there are long lists of treatments with results that are marginally effective at best.