Effectively treating vascular and pigmented lesions — from common facial telangiectasias to more challenging hemangiomas — relies on identifying the appropriate tools and then honing one’s technique to achieve the best results. However, more often than not, patients want to make the most of their sessions by undergoing concomitant facial resurfacing to improve wrinkles and texture changes related to repeated sun exposure, according to William F. Groff, D.O., who practices alongside aesthetic laser pioneer, Richard Fitzpatrick, M.D., at the La Jolla Cosmetic Surgery Centre, in La Jolla, Calif. In these cases, Dr. Groff tells Cosmetic Surgery Times, a combination of two or more lasers is often the best approach. Here, Dr. Groff offers tips and perspective on wrinkle and vascular and pigmented lesion treatment strategies that result in patients whose post-procedure appearance is ultimately the best form of marketing.
RESULTS DELIVERED The most common facial lesions that patients request treatment for are wrinkles, telangiectasias and solar lentigines according to Dr. Groff, who adds that these are followed in frequency by rosacea, melasma, cherry angiomas and spider angiomas.
“Facial telangiectasias, cherry angiomas and spider angiomas are fairly easy to treat if you have the right tools,” says Dr. Groff. They can all be treated very safely and effectively with pulsed dye lasers (PDLs) in just one or two sessions. “PDL has a long track record and is certainly considered the gold standard, so if the practitioner wants to treat both vascular and pigmented lesions, the PDL is one unit that can be counted on to deliver reliable, predictable and safe results. We have about 20 lasers in our practice and the PDL is probably the safest. The chance of having a problem or complication is extremely rare.”
Dr. Groff’s technique for facial telangiectasias comprises the use of a Candela V-beam Perfecta PDL, using the 10 mm spot size with 7.5 to 10 J/cm2. “I would usually use a 6, 10 or 20 ms pulse duration [depending on the size of the vessels], and it could take anywhere from one to three sessions at the most,” he explains. Larger vessels require treatment with longer pulse durations. David J. Goldberg, M.D., J.D., adds that, “A variety of other lasers and light sources can also be successfully and safely used to treat such vascular lesions. Among the more popular wavelengths besides the 595 PDL are the 532, 940, 980 and 1064 nm wavelengths.” Dr. Goldberg is director of Skin Laser & Surgery Specialists of NY/NJ, and clinical professor of dermatology/director of laser research at the Mount Sinai School of Medicine in NYC.
There is a high demand for facial laser resurfacing in Dr. Groff’s practice and almost every person who comes in for resurfacing has brown spots and telangiectasias. “But no matter what kind of fractional resurfacing device you use, most telangiectasias and some brown spots remain.” To get the best results, Dr. Groff recommends using a combination of lasers. “There’s not one box that does it all and does it all the best,” he says.
For a patient who has facial telangiectasias, solar lentigines and wrinkles, Dr. Groff recommends using the PDL to remove the capillaries, the PDL or Q-switched alexandrite to remove the lentigines, then immediately treating with fractional CO2 resurfacing all in one session. “The results are much better than if you use any of these technologies alone,” he says. “Dr. Fitzpatrick and I have been doing these combination treatments for years, and we’ve never had any complications from combining lasers in one session. Our results are excellent and patients appreciate not having to come back for separate treatments, which would incur more social downtime. There’s a synergistic effect where the results are much better when these treatments are done at the same time, in comparison to doing them separately,” he adds.
Taking the synergistic effect one step further, Dr. Groff recommends pretreating with BOTOX around the glabella, the forehead and the crow’s feet area one to two weeks before performing fractional resurfacing. “If you do this, those muscles are relaxed so they’re not contracting and etching lines into freshly resurfaced skin,” he explains.
STACKING TREATMENTS In the majority of these cases, patients who are seeking resurfacing and treatment for telangiectasias also want to be rid of the vertical upper lip “smokers’ lines” that are commonplace among women over the age of 40. “The gold standard for erasing these lines is still traditional multiple pass CO2 laser resurfacing in combination with erbium laser resurfacing. So even though fractionated CO2 will soften the lines, if the patient wants those lines to be gone you still need multiple pass CO2 and erbium laser resurfacing,” he explains. “In our practice, if we’re going to resurface a woman’s facial skin, we’ll use a fractional CO2 over the entire face with the exception of the upper lip where we’ll perform traditional multiple pass CO2 and erbium resurfacing in addition to using the PDL and the Q-switched alexandrite laser to address the telangiectasias and brown spots, respectively. We use these lasers back to back in the same treatment session. That’s really the way to get the best results,” Dr. Groff says. With regard to these challenging upper lip lines, Dr. Goldberg adds that, “Although fractional nonablative lasers do not typically lead to improvement of upper lip lines, many clinicians have also seen great results from ablative fractional lasers emitting 2790, 2940 and 10,600 nm wavelengths.”
For pigmented lesions, Dr. Groff opts for Candela’s TriVantage, a Q-switched alexandrite laser, which delivers energy through a fiber optic cable, giving it a homogeneous result with less variation from pulse to pulse. “We consider this laser the workhorse of our practice. It’s fast and extremely effective,” he says. The TriVantage offers Q-switched 1064 nm and 532 nm wavelengths, as well as a 755 nm wavelength, so, in addition to treating pigmented lesions, it is also effective for tattoo removal of many colors. “Previously removing multicolor tattoos meant using multiple lasers, but with the TRiVantage we’re able to remove all colors except for white, yellow and fluorescents,” he says.
Pulsed dye laser (PDL, 595 nm) is the current treatment of choice for port-wine stains (PWS), but 25–50% of treated lesions do not demonstrate a significant improvement.
Combination of laser may improve treatment efficacy, especially those using the synergies between PDL and Nd:YAG 1064nm laser. There is a growing body of research and anecdotal evidence that the dual wavelength approach shows efficacy with less discomfort for the patient.
Get this from the pros: “These days, it’s perfectly reasonable to expect your skin to get better as you age — no matter what the date on your driver’s license,” says Dr. Ranella Hirsch, president of the American Society of Cosmetic Dermatology and Aesthetic Surgery and a cosmetic dermatologist in Cambridge, Mass.
There are many “secrets” to good looking skin for you 40s, 50s, 60s and beyond. Dr. Hirsch published a very good decade-by-decade skin care guide on MSNBC today. Strongly recommended read. It is an excellent blend of skin care recommendations and professional laser treatments.
All basic recommendations are very good and applicable to many. However, the true secret to your healthy and young looks is knowing what will actually work on your skin. It’s hard to figure it out without a little help from an aesthetic professional, and an educated consumer can get a lot more from a visit to an aesthetic laser clinic.
Regular skin care may be beneficial in the long run. You can spend thousands on latest cosmeceuticals and medical grade creams and lotions. Provided you can afford the expense and the time needed to follow the regimen you may have great skin well into your 50s. Bear in mind though, sun exposure may ruin months of hard work and patience in a few minutes.
Sun avoidance and sun protection are by far the most important factors determining health and looks of your skin. Everything else is secondary.
Light-based and radio frequency based technologies offer a totally different level to skin care. There are many safe and non-invasive lasers, intense pulse light and LED machines, which will make a big difference in providing a real skin texture improvement, new collagen formation, skin tightening and plumping.
Botox and dermal fillers are household terms these days and people are no longer shy to talk about it. In fact, according to survey statistics released today by the American Society for Aesthetic Plastic Surgery (ASAPS), nearly 9 out of 10 respondents (87 percent) openly discuss their dermal filler treatments with others, and 7 out of 10 (70 percent) receive support from the people they told.
This trend shows that aesthetic injectable treatments continue to evolve into mainstream and widely accepted options for the everyday use. Survey results found that the typical aesthetic injectable patient is a married, working mother between 41-55 years of age with a household income of under $100,000. The survey also found that women receiving aesthetic injectable treatments are health-conscious and philanthropy minded, with the majority incorporating exercise (95 percent) and healthy eating habits (78 percent) into their lives, and many volunteering with charitable organizations that matter to them (32 percent).
In addition, nearly seven out of 10 respondents believe that BOTOX® Cosmetic (72 percent) and hyaluronic acid dermal fillers (65 percent) are important parts of their aesthetic routine. “Most people have great success with BOTOX® Cosmetic and dermal fillers; however, we need to make patients aware that even though injectables are not ’surgery,’ their administration is a medical procedure with risks that depend on the training and experience of the clinician, the clinical setting and the technique used,” says Laurie Casas, MD involved in the survey.
Hyaluronic acid dermal fillers ranked as the third most popular procedure performed last year. The most common injectable dermal fillers are Restylane, Juvederm, Sculptra, Zyderm and Zyplast, and Bio-Alcamid.
Dermal fillers are being used to reduce or eliminate wrinkles, raise scar depressions, enhance lips, and replace soft-tissue volume loss.
Several classes of dermal fillers are marketed in the United States today. They include:
New promising dermal fillers are in development that will offer superior capabilities in the future.
Autologous (your own) fat is also used as a dermal filler. Your surgeon can take fat from one area (where you do not want it) and inject it into another (where you want it, such as facial wrinkles, or any other area with a loss of volume). This procedure is called lipoinjection or lipografting.
Injection of fillers usually requires the use of either a topical numbing cream or a local injection of numbing medication. Then, using a small needle, the dermal filler is injected into each wrinkle or scar that requires treatment. Some mild burning and stinging is normal and quickly resolves.
The results can last from three months to five years, depending on the filler being used. Collagen provides the shortest duration with effects lasting anywhere from three to six months. Restylane tends to last a bit longer with effects lasting from six months to one year. Radiesse can provide results that last greater than 3 years.
These two are very compatible. In fact, if your aesthetic physician is trained and has lasers, he or she can enhance your results dramatically by doing a combination treatment, which may stimulate the growth of new collagen and improve the skin texture. Typically IPL or laser photo rejuvenation (photo facial) is done as a separate procedure. An advanced aesthetic clinic will be able to offer a dermal filler-laser treatment combination in one seating.
Celebrities are sporting plump faces and full cheeks that don’t come naturally unless you’re in your twenty-something.
Dr. Samuel Lam performed her fat transfer and has written two books on fat transfer. He says patients fly in from all over the world for the procedure. Cutting and pulling is so 90′s.
There are several choices of facial fillers and if done correctly, fat transfer will last a very long time.
Fat transfer and laser assisted facial photorejuvenation may go hand in hand to enhance the results.
In a recent article in Dermatology Times the following statement attracted our attention:
“Among U.S. medical applications, photodynamic therapy (PDT) ranks as probably the most important underused laser technology, says Jill Waibel, M.D., a dermatologist in private practice at Palm Beach Esthetic Dermatology & Laser Center, West Palm Beach, Fla., and a volunteer faculty member with the University of Miami Department of Dermatology.”
Our quick study of the issue revealed similar results. PDT has been widely adopted in Europe, where phyicians use PDT for skin cancer, ovarian cancer and other cancers. PDT has been known to prevent skin cancer and to successfully treat pre-cancers of the skin. The U.S. healthcare system spends billions of dollars annually to freeze actinic keratoses (AKs) or to excise skin cancers only after they’ve developed.
Additional applications for PDT include treating actinic chelitis, basal cell carcinoma, nevus syndrome, disseminated porokeratosis, acne keloidalis nuchae, pseudofolliculitis barbae and hidradenitis suppurativa.
Blue light low power light is typically used in PDT. This type of lasers is not the main focus of our coverage, but we thought it is worth mentioning since this procedure is borderline with aesthetic lasers.
Arch Facial Plast Surg. 2005 Jul-Aug;7(4):251-5
Authors: Carniol PJ, Vynatheya J, Carniol E
OBJECTIVE: To evaluate the efficacy of treatment of established acne scars with a sequential combination of treatment using a 1450-nm, midinfrared, nonablative diode laser with dynamic cooling spray and 30% trichloroacetic acid peels.
METHODS: In this prospective study 9 patients with atrophic rolling, boxcar, or both types of scars received 4 monthly treatments using a 1450-nm, midinfrared, nonablative, diode laser with dynamic cooling spray followed by 2 bimonthly treatments with 30% trichloroacetic acid peels. Blinded evaluators and the patients rated the results.
RESULTS: The group of patients in this study had a greater improvement in their acne scars than has been reported for nonablative laser treatments by other authors. Comparing the results of treatment 2 months after the laser treatments with 2 months after the chemical peels, the patients had a greater improvement after the additional chemical peels. There were no complications in this study. The patients were able to continue all of their regular activities throughout the study.
CONCLUSION: This sequential treatment regimen using the 1450-nm, midinfrared, nonablative diode laser with dynamic cooling spray and 30% trichloroacetic acid peels produced a noticeable improvement in the acne scars without any associated morbidity.
PMID: 16027346 [PubMed - indexed for MEDLINE]