BEFORE AND AFTER PHOTOS
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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 is well-served with a basic understanding of the different types of laser treatments available, their pros and cons, and alternative treatments. The cost of not having this knowledge is that you may end up having a treatment of questionable value in our “buyer beware” marketplace. This is particularly true of treatments that advertise minimal recovery and no downtime. A healthy skepticism is your best defense.
The Ultrapulse laser was introduced to me in 1995 at a meeting in Marina Del Ray, California. 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 had arrived at this meeting 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 eyelid surgery (blepharoplasty) and facelifts to produce overall facial rejuvenation. I started using it in my practice 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 turned out to be the correct one and remains unchanged in my practice today. Some operators, however, pushed the limits, and soon negative results were reported.
The CO2 Laser Controversy
Overtreatment 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 common, 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 underrecognized 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 from enthusiastic embrace of a new technology to resumption of traditional alternatives.
Erbium laser resurfacing is also an ablative laser treatment, with less skin penetration, similar to a single pass with the CO2 laser. Because the treatment is superficial, the recovery time tends to be quick (several days). Of course, with less penetration there is also less skin tightening effect compared with the CO2 laser.
Nonablative Light Treatments
“Nonablative” lasers were introduced to avoid the recovery time associated with systems that vaporize the surface layer. Nonablative systems include intense pulsed light (IPL), which was popularized as a “photo-facial,” usually administered in a series of treatments.
Nonablative lasers combine a near-infrared laser to heat the dermis and a cooling device to avoid burning the epidermal skin surface, more of a “bake” than a “broil.” This combination avoids vaporization of the epidermis, the hallmark of ablative techniques, eliminating the healing time needed to resurface the skin with new skin cells.
It seemed like a good idea. However, I’ve tried some of them, including the Nd:YAG 1320 nm pulsed laser (Cooltouch, Inc., Roseville, Ca.) and the results were underwhelming. There was little perceptible improvement in wrinkles and, as expected for a nonablative system, no improvement in the surface brown spots.
Not surprisingly, surface problems respond to ablative treatments, not dermal heating. The nonablative laser produced minimal improvement in wrinkles and did not treat sun-related epidermal damage—two strikes against it already. It does not matter if the recovery is quick if the treatment does not produce results, and patients clearly prefer one treatment to a series. Despite aggressive marketing, the nonablative laser did not catch on.
“Fractional” lasers attempt to achieve the results of an ablative laser treatment without the recovery time. These lasers make uniform patterns of thousands of tiny holes in the skin, preserving bridges of unaffected 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), so to speak.
Despite an intriguing concept, that looks great on the drawing board, the original Fraxel SR Laser (Solta Medical, Inc., Mountain View, Ca.), introduced by Reliant Technologies (Palo Alto, Ca.) in 2003 did not seem to be very effective, probably because of inadequate heating of the deep layers. Operators recommended 4–6 treatments, spaced a week apart, which tells you right away that the results were not dramatic. Perhaps the fractionated concept was the right idea, but the 1500 nm wavelength used was insufficient to cause skin tightening. Heavier “artillery” was needed. Upgrades soon appeared.
The UltraPulse ActiveFX laser (Lumenis Inc., Santa Clara, Ca.) and DOT Therapy laser (DEKA Laser Technologies, Inc., Carlsbad, Ca.) are examples of the next generation of fractional lasers. I have had the opportunity to use both and observe the results. These lasers offer the advantage of the CO2 laser’s longer wavelength, with its greater thermal effect, but can still be done comfortably on patients after pretreatment with a potent topical anesthetic.
As might be expected with its 10,600 nm wavelength, the fractional CO2 laser (Fraxel Repair, Solta Medical, Inc., and DeepFX, Lumenis, Inc.) provides greater heating (called coagulation necrosis) and therefore greater tightening of the tissues. Investigators reported that these lasers approach the effectiveness of the traditional fully ablative CO2 laser. There is no need for a course of treatments. One treatment usually suffices, although a touch-up may be done later.
(Left) Fractional and (right) ablative laser skin resurfacing. Fractional laser treatments preserve a bridge of skin between the holes. The skin heals quickly as adjacent skin cells heal the holes from the sides. Ablative treatment fully vaporizes the epidermis. The skin heals from the hair follicles and sweat glands. Cells migrate from the base of these skin appendages to the surface. The zone of coagulation necrosis extends beyond the vaporized tissue, heating the dermis, and causing the skin to tighten.
Result vs. Recovery Time
For patients contemplating laser resurfacing, the question becomes, What is more important, a more impressive result or a shorter recovery time? Local anesthesia or I.V. sedation? For many of my patients, who wish to do this once if possible and not return for a long time (“nothing personal, doc”), the result is their priority. A few days more recovery time is an acceptable trade.
Of course, this preference for results may be affected by the surgical orientation of my practice, compared with, for example, a dermatology office. I often perform surgical procedures simultaneously with laser resurfacing (fat injection, for example), and I am fortunate to have easy access to an on-site surgery center and anesthesia.
The Importance of Epidermal Treatment
The fully ablative laser treats the epidermal damage, which is a continuous problem, in a continuous fashion, while also producing skin tightening because of the thermal effect in the dermis below—two hits already. The advantage and disadvantage of the fractional laser is its noncontinuous ablation of the epidermis, which allows faster healing but compromises the epidermal result. As the fractional CO2 laser becomes more ablative, it approaches the effectiveness of its fully ablative predecessor, but there is less advantage in healing time. The comparison is no longer between a lunch-hour procedure and a week off work. The difference in recovery time is reduced to several days.
Laser recovery time becomes a moot point in patients who are having other procedures, such as a facelift, simultaneously. They won’t be looking presentable for at least a few weeks anyway. To obtain the best epidermal result and make the most of my patient’s precious recovery time, I prefer the ablative CO2 laser, but I typically make only one or two passes. I want my patient to recover quickly. I still want my cake and eat it too.
Making a Decision About Laser Treatments
Many patients are willing to accept a reasonable downtime provided they get results. This is particularly true for patients who are having other procedures such as blepharoplasties (eyelid 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 unrewarding for a physician to have a patient comment, “I don’t see a difference.” More important, it is unrewarding for the patient, who has gone to some trouble and expense. Unfortunately, there is a long list of treatments with results that are marginally effective. Less is less. Patients may grumble about the recovery phase, but it’s better to grumble about that than about no results. Ablative laser resurfacing works, and the benefits in terms of less wrinkling and age spots can last for years.