Injectables, dermal fillers, laser surgery, plastic surgery, photorejuvenation, laser skin treatments… In the face of nose-diving portfolios and little disposable income to go around, should ridding the face of wrinkles really be a priority?

Dr. Philip Prioleau, dermatologist, and Dr. Cap Lesesne, plastic surgeon, both in private practice on Manhattan’s Upper East Side debate the issue of priorities in cosmetic procedures.

In addition to the LightSheer(R) Duet(TM) Diode Laser System, Lumenis(R) rolled out another laser at the 2009 American Academy of Dermatology (AAD) Annual Meeting in San Francisco.

The system is called UltraPulse 4x for Fractional C02 Rejuvenation, which will significantly reduce treatment times to provide cost-effective-high value cosmetic options during challenging economic times.

“The cosmetic industry is certainly feeling the effects of the economy and the resulting decline in elective, fee-per-service procedures. We have focused our development efforts on time and cost saving innovations that will provide physicians with innovative and competitive solutions that can sustain, differentiate and grow their business during challenging times”, said Mr. Robert Mann, General Manager of Lumenis Global Aesthetics and Dermatology.

The UltraPulse CO2 Laser System delivers ActiveFX, DeepFX and TotalFX fractional resurfacing in a single treatment with only a single pass. The new UltraPulse 4X upgrade now covers twice the treatment area and twice the speed. These changes significantly improve practitioner and patient acceptance of fractional resurfacing, as well as increase the revenue potential for physician practices and clinics.

The UltraPulse 4X has a micro-second pulse, which allows efficient ablation, lower downtime and more comfortable treatment. The UltraPulse 4X now covers twice the surface area per scan, expanding from 7x7mm to 10x10mm and delivers twice the pulse speed, from 300Hz to 600Hz.

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Fast is good when patients, for whom time is money, are lining up at the door of the physician’s office. What’s the rush in a slow economy? These days, esthetic practices are looking for patients who are looking for jobs. Bothe have time to spare. Affordability of a laser procedure is key, but it is unlikely that with the high cost device physicians will be able to drop their fees.

Photoaging of the skin is a fact of life. Unpleasant, but manageable. Lasers and light-based treatments are extremely useful tools, which should be used by all clinics offering complex anti-aging services.

To obtain the most successful results, protocols involving single or combination systems can be used, depending on skin type and the stage of the photodamage. In the last years, the trend is to choose noninvasive or minimally invasive treatments, with the aim of reducing the risk of side effects, complications, and, most importantly, the downtime.

Selective photothermolysis by lasers and intense pulse light devices is presently considered the most suitable technique by a growing number of practitioners. A large range of wavelengths can be used to safely achieve good results for patients with fair skin. The 1064 nm Nd:YAG has become the golden standard for treating the skin of color.

Photodynamic therapy is another effective tool in photoaging treatment, especially in the presence of precancerous conditions.

In mild and severe photoaging, ablative laser resurfacing is a particularly successful technique, although requiring a more skilled hand.

New systems using fractional photothermolysis are gaining ground in the marketplace. The non-ablative group has yet to prove its advantages over established technologies. The newest trend is ablative fractional lasers. More research of the efficacy of these devices in direct comparison with existing ablative lasers will be required to prove the claimed and percieved higher efficacy and less risks.

Obviously, lasers and light-based treatments alone might not be sufficient to control all aging symptoms. Combination treatment with botulinum toxin, filling agents, chemical peels, systemic and topic antioxidants should be used to improve the final clinical outcome.

A very good study by doctors Kono T, Frederick Groff W, Chan HH, Sakurai H, Yamaki T of the Department of Plastic and Reconstructive Surgery in Tokyo Women’s Medical University, Tokyo, Japan (tkono@prs.twmu.ac.jp)  just came out.

Pulsed dye laser (PDL) treatment of hypertrophic port-wine stains (PWSs) on the lips has demonstrated poor efficacy and a potential risk of dyspigmentation. PDL-resistant hypertrophic PWS can be safely treated with much greater efficacy with deeper penetrating lasers such as a 1064-nm neodymium:yttrium-aluminum-garnet (Nd:YAG) laser. 80% of the treated patients showed good to excellent improvement without complications.

The first medical lasers to be developed were continuous wave lasers that produced a continuous beam of radiation that was subsequently absorbed by a target. Although this constant laser light could effectively treat certain dermatologic conditions, its use was limited by the fact that the laser energy not only altered the target but also “spilled over” into adjacent tissues, causing unwanted collateral damage and scarring. As our understanding of the interplay between living tissue and laser physics evolved, however, so did our ability to restrict laser damage to a specific target. The concept of selective photothermolysis developed by Anderson and Parrish in 1983 gave us the tools necessary to be more precise and safer with laser energy.

Selective photothermolysis states that a specific chromophore or target can be selectively destroyed with minimal collateral thermal tissue damage if the laser wavelength matches that absorbed by the chromophore, and if the target is exposed to the laser energy for an interval less than its thermal relaxation time. The thermal relaxation time is the time it takes a given target chromophore to lose 50% of its absorbed heat energy.

Selective photothermolysis revolutionized laser technology and paved the way for a new generation of lasers that are designed to deliver a set wavelength for a precise duration, resulting in greater specificity and safety. The pulsed, quality Q-switched, and scanned systems are examples of such laser technology. Other so-called quasi-continuous laser systems also attempt to adhere to the theory of selective photothermolysis by limiting pulse durations from a continuous beam source through shuttering or chopping of the emitted laser beam. The usefulness of these systems is often limited owing to their high repetition rates or moderately long pulse durations, causing the target to experience the laser’s energy as if it were a continuous wave.

Lasers emit a coherent and monochromatic light beam, whereas pulsed lights produce a polychromatic light whose bandwidth is selected by adapted filters. The skin’s chromophores are made up of water, hemoglobin, and melanin, to which must be added the exogenous pigments of tattoos. Each chromophore has its specific absorption spectrum. Lasers’ main mechanisms of action are the photothermal effect and the photomechanical effect.

With the previously mentioned concepts in mind, the side-effect profile of a specific laser can be predicted in general terms, based on its wavelength and mode of operation. As a group, continuous wave and quasi-continuous lasers have a higher risk of scarring and textural changes through thermal buildup and heat diffusion to normal skin structures. Lasers designed on the theory of selective photothermolysis are more specific and have a lower risk profile.

Depending on the wavelength and pulse durations delivered, pigmentary changes, epidermal cell injury, textural changes, and crusting and tissue splatter can potentially occur. It is important to remember that even the safest lasers can cause injury if used incorrectly. Repetitive or overlapping pulses, excessive energy or power settings, and improper patient selection can potentially result in a high rate of morbidity with the use of any medical laser.

Complications might be encountered with any currently available laser systems, however, today’s laser technology is universally accepted as very safe for the patient.

Lasers used in the aesthetic medicine are divided into ablative and non-ablative groups.

Among the ablative lasers are the CO2 and Erbium:YAG (Er:YAG) lasers. The predominant use of both is for static wrinkles, as opposed to dynamic wrinkles—those created by smiling or laughing. They can also treat dyspigmentations on the face, neck and other parts of the body. As a general rule, we do not use a laser to replace a knife to cut into tissues, but as a tool to resurface. Thus, procedures done with either CO2 or Erbium lasers are typically defined as “laser skin resurfacing”. If you smile and you get crow’s feet, this is best treated with botox injections. However, if you are sitting at rest and you have fine static lines under your eyes, this is best treated with one of these two laser groups.

CO2 lasers are largely considered to be the first cosmetic lasers, which are used less and less these days. The most popular laser among plastic surgeons in the U.S. is the Erbium:YAG. It is used most frequently for fine lines under the eyes and around the mouth for the vertical lip lines. Full face resurfacing, both deep tissue resurfacing and gentle laser peels, are also very commonly offered by physicians’ aesthetic practices.  These lasers are also used to treat wrinkles in conjunction with facial surgery, such as a facelift or an eyelid surgery (Blepharoplasty), in one sitting. The big criticism with CO2 was that it caused a lot of undesired pigmentation, and some experts say that the CO2 laser is “unforgiving”, especially in the hands of the less experienced. CO2 typically require a much longer healing time (downtime) and more post-operative care. 

The Er:YAG laser provides superficial ablation and is generally used for more superficial rejuvenation. Most people now prefer laser procedures that have minimal associated recovery. Erbium is a preferred modality for such procedures as photoaging, acne scars, superficial cutaneous problems, and rhinophyma. Some laser systems provide for thermal-coagulative and ablative properties. These systems are considered as intermediate resurfacing lasers, providing faster healing and results that are typically in between those of the CO2 and standard Er:YAG lasers.

Up until the mid 1990s, phenol peeling (aka chemical peels) was the most popular technique for treating wrinkles and preceded facial resurfacing laser techniques, but this technique also commonly caused hypopigmentation. Even if you did not go too deep, phenol is melanotoxic and would still cause some degree of depigmentation. Besides, the level of control in the application of chemicals is limited to the expertise of the provider.

Phenol is now experiencing a resurgence in popularity, as is the CO2 laser. Cosmetic physicians are getting excellent results with phenol peels and CO2 lasers because the chemistry is now much better understood, which allows them to achieve better results with fewer adverse events. Although ablative resurfacing lasers can achieve excellent results, their major drawback is they do cause significant edema and erythema, which may last for many weeks, and they can cause potential scarring. Therefore, the recovery times are relatively long.

Laser-based devices for aesthetic treatments are the industry “gold-standard,” although the efficacy of devices based on Intense Pulsed Light (IPL) technology is improving and the gap between IPLs and lasers is closing. Laser technology is expected to remain the only effective light-based treatment in specialist areas such as large pigmented lesion removal, tattoo removal and deep vascular treatments, but IPL-based devices are becoming more popular for the more mainstream aesthetic treatments, especially in the high growth market of skin rejuvenation.

Medical experts, who have used both IPL devices and lasers, would point out the following reasons why they prefer lasers:

• It is harder to predict results with IPL due to its broad-spectrum of light and multiple wavelengths
• IPLs are not safe to use around the eye
• IPLs are not safe on the skin of color and tanned patients

Despite not quite matching the performance of some premium laser-based systems, IPL technology has its advantages for the core aesthetic treatments such as hair removal and skin rejuvenation.

Various sources and study groups forecast IPL-based devices to enjoy growth rates of 10-12% in hair removal and skin rejuvenation. Unlike for laser-based devices, the IPL-based device market is more accessible to non-physicians, and hence IPL-based devices are commonly found in spas across the U.S. and Europe.

As IPL-based devices are not designed to treat complex skin conditions, practitioners do not have to be as highly trained as they do for laser-based devices. IPL-based devices typically come with two simple-to-use handsets, one for each of the most popular applications, hair removal and skin rejuvenation. Adding to the appeal of IPL-based devices for a non-physician is the lower price with respect to a laser-based system, whilst maintaining the core applications essential to a light-based aesthetic practice or medical spa.