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Benefits to Combining Laser Modalities

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.

The concept of non-ablative fractional photothermolysis was introduced to the market in 2003 as an answer to the need for effective, yet low risk, skin resurfacing techniques. Unlike conventional ablative (CO2 and Erbium) and non-ablative lasers, fractional ablative and non-ablative photothermolysis treats only a fraction of the skin, leaving up to a maximum of 95% of the skin uninvolved. The undamaged surrounding tissue allows for a reservoir of viable tissue, permitting rapid epidermal repair.

Non-ablative fractional photothermolysis is currently approved by the US Food and Drug Administration (FDA) for the treatment of pigmented lesions, periorbital rhytides, skin resurfacing, melasma and soft tissue coagulation, acne and surgical scars, and actinic keratoses. However, its off-label use is clearly more extended. Many practitioners would agree that this first wave of fractional lasers has delivered very limited clinical efficacy.

See larger chart

fractional-ablative-laser-treatment

In 2007 the concept was further developed, and ablative fractional photothermolysis was introduced, using an erbium yttrium aluminium garnet (Er:YAG) or carbon dioxide (CO2) laser. These devices are FDA cleared to treat wrinkles, rhytides, furrows, fine lines, textural irregularities, pigmented lesions and vascular dyschromia. (more…)

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  • Filed under: Device Review, LT | fractional
  • CO2 and Erbium laser skin resurfacing is a very efficient procedure to remove wrinkles, acne scars, blemishes, growths, and sun-damaged skin blemishes. The laser allows the body to produce new collagen and generate new skin. The result is usually “years younger” skin. Improvement continues as the aged and sun-damaged deep collagen areas continue to regenerate and repair for three to six months after treatment.

    Laser skin resurfacing basics

    How long will the improvement last?

    No one can say for sure, but many laser physicians believe that you can expect the results to last for several years. How long may depend on your unique skin type and upon your post-treatment skin care. Think of the laser as “turning back the clock” so to speak, so that your skin again resembles its fresher appearance of years past. Your new skin remains dynamic and alive and it should take many years before your skin appearance manages to catch up with where it was before your treatment. Much depends on how carefully you protect your new skin from damaging sun-exposure. You have a second chance at slowing down the sunlight-related aging process. (more…)

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  • Filed under: LT | skin resurfacing
  • laser-resurfacing

    Still horrified by laser blasting of facial wrinkles followed by months of redness? This is so 90s!

    New generation of aesthetic lasers is safer and more selective in treating just what the doctors says you need: wrinkles, age spots, broken capillaries, saggy skin, etc. The result? Faster healing, so you can get back in makeup and return to work with smoother skin in as little as 24-48 hours. Well… it depends. Here is a brief guide to different laser treatments so you can better understand your options.

    Ablative Carbon Dioxide (CO2) Resurfacing

    This is the skin-wounding original 1990s procedure.

    Used for: hard-core lines and acne scars; can also tighten loose skin but is safe only for fair skin types only.

    How it works: By blasting and burning away the skin’s top layer, this aggressive single treatment bulldozes wrinkles and everything else in it path.

    How it feels: you should not feel anything during the procedure since it is performed under general anesthesia. Recovery time: you are a burn victim for several days with open wounds, which ooze and bleed, followed by 7-10 days of rawness while your obliterated epidermis regenerates, and pinkness for 4-5 months.

    Price: $4,000 to $8,000

    Efficacy/Results: Excellent (if done right) but in a few months after the treatment.

    Ablative  Erbium Laser Resurfacing

    Used for: fine to deep wrinkles and acne scars; can also tighten loose skin, doctor must be cautious with darker skin types.

    How it works: By evaporizing layers of epidermis (the skin’s top layer).

    How it feels: This proceudre is performed under a topical or local anesthesia and you may experience some burning discomfort. Recovery time: depending on the depth of resurfacing, you will feel from slight to mild oozing for 2-5 days, followed by 7-20 days of pinkness, which can be covered by make-up.

    Price: $1,500 to $3,000

    Efficacy/Results: Good to excellent depending on the depth of resurfacing.

    Ablative Fractional Resurfacing

    Types of lasers used: either CO2 or Erbium (Er:YAG).

    Used for: Smoothing fine-to-deep lines and evening out brown spots in a single treatment. Can also help tighten lax skin and remove some small spider veins.

    How it works: The laser beam strikes the skin in thousands of tiny spots, destroying tissue a millimeter deep in those microscopic spots only (think perforated paper). Surrounding skin remains intact, allowing for faster recovery than the original ablative devices but more intense results than the nonablative fractional laser. The hole-punching fires up the body’s wound-healing response, which generates collagen and smooths wrinkles. It’s ablative and therefore riskier for patients of color, but can be executed successfully at a doctor’s office.

    How it feels: Typicaly performed with local anesthesia similar to what you’d get in a dentist’s office. After 15 minutes of post-treatment discomfort and an application of ice packs, pain is minimal. For 24 to 36 hours, skin oozes, bleeds and peels, followed by five days of crustiness. Once crust peels, new, pink skin emerges and makeup can be worn; complete healing within two weeks.

    Price: $1,500 to $5,000

    Efficacy/Results: Average to good.

    Nonablative Fractional Resurfacing

    Non-ablative simply means that your skin will not actually be resurfaced, i.e. top layer of the skin, aka epidermis, will remain intact.

    Used for: Smoothing fine-to-moderate lines, evening out brown/age spots, and improving overall texture and glow.

    Downtime: typically none, but the skin may be red for a couple of days.

    How it works: The laser penetrates deep into the skin, heats and provides controlled thermal injury to the connective tissue, which stimulates collagen production. No oozing no raw skin. It’s typically performed over a course of three to five 25-minute treatments, one to two months apart. This procedure is safe for darker skin types.

    How it feels: like the heat is building up in your skin, but no pins and needles. May feel like a bad sunburn for a few minutes after the procedure is over; afterward, skin is pink and sandpapery for three to five days but can be camouflaged with concealer.

    Price: $600 to $1200 per treatment depending on the actual laser modality and doctor.

    Efficacy/Results: Average to good depending on a number of treatments.

    Intense Pulsed Light (IPL)

    Used for: Eliminating brown spots and other sun-induced discoloration and spot-treating broken capillaries. No effect on wrinkles.

    How it works: IPL devices are not lasers, unlike lasers they emit a broad spectrum of light. Short pulses of bright white light pinpoint brown pigment cells and redness, which are damaged when they absorb the light and the heat it creates. Safe for most skin types, but a doctor may dial down intensity for darker skin tones to avoid slim risk of de-pigmentation.

    How it feels: Like a sunburn. Patients experience slight swelling and pinkness the day of the procedure, but there’s no downtime, which is why it’s often categorized as a “lunchtime” treatment.

    Price: $400 to $600 per treatment.

    Efficacy/Results: Average and multiple treatments are required.

    hyperpigmentation in dark skin individuals

    Dyschromias, in particular hyperpigmentation, are major issues of concern for people of color. Pigmentary disorders such as melasma and postinflammatory hyperpigmentation can cause psychological and emotional distress and pose a negative impact on a person’s health-related quality of life.

    The precise etiology of these conditions is unknown. Therapies for melasma and postinflammatory hyperpigmentation target various points during the cycle of melanin production and degradation. Therapies for these conditions include topical agents and resurfacing procedures. Hydroquinone remains the gold standard of topical agents. Other efficacious agents include kojic acid, azelaic acid, mequinol, and retinoids. Cosmeceutical agents include licorice, arbutin, soy, N-acetyl glucosamine, and niacinamide.

    Laser resurfacing procedures are the safest and most efficacious options to treat melasma and hyperpigmentation on the skin of color. These procedures are best used in combination with topical bleaching agents. Given the propensity of darker skin to hyperpigment, resurfacing procedures should be used with care and caution. Maximal results are best achieved with repetitive, superficial, resurfacing modalities.

    In addition, ultraviolet protective measures such as broad-spectrum sunscreens are fundamental to the successful management of these conditions.

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  • Filed under: LT | skin resurfacing
  • Video of Laser Skin Resurfacing

    This is our most recent (constantly updated) collection of video materials demonstrating laser skin resurfacing with different aesthetic laser modalities: CO2, Erbium and ablative fractional lasers.


    Click on the banner to learn more about skin cleansing More info about Clear Pores acne skin care product


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  • Filed under: Video | laser skin resurfacing
  • This is our most recent (constantly updated) collection of video materials demonstrating Fraxel laser skin rejuvenation, Fraxel and fractional laser skin resurfacing technology, fraxel CO2 laser acne scars, Fraxel laser skin tightening, and Fraxel laser wrinkles.


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    As the number and variety of lasers increase, it is timely to review which lasers are best for which clinical procedures. This well illustrated text from respected authorities provides the answers for a number of commonly encountered problems. Even established laser surgeons will be interested to learn about newer laser varieties, such as fractionated lasers, and on methods to combine additional and adjunctive procedures for a better esthetic result.







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