By Shervin Naderi, MD, FACS
In today’s plastic surgery practice, it is impossible to avoid running into an ad or an article about the newest and greatest doctor using the newest and greatest Laser for facial rejuvenation, melting fat, acne, hyperpigmentation, or some other imperfection! It is no secret that the word “Laser” is a “cash term” used for savvy marketing and advertising. The word elicits thoughts of modernity, technology, safety, precision and competence. Many patients have been erroneously taught to believe if Dr. A uses a Laser to do a certain procedure then he and his results must be better than those of Dr. B.
So what is the truth? Are Lasers all that important in Plastic Surgery? Should you search for doctors who possess lots of Lasers in their offices? Is there an advantage to using Lasers over other modalities? Are Lasers safe? Does the use of a Laser justify its cost? Who can operate a Laser? Who is a good candidate for Lasers? Are there better options out there? What are the best Lasers? These are likely some of the many questions on prospective patient’s minds as they research Facial Cosmetic Procedures.
After working with a long list of Lasers and talking to an exhaustive list of Laser sales persons over the last 9 years I can give you a few valuable pearls to help guide you through your search for the Holy Grail and the fountain of youth! To begin with the term “LASER” is actually an acronym that stands for Light Amplification by the Stimulated Emission of Radiation. In pure and simple terms this refers usually to a single wavelength of light that travels parallel and coherently. It was in 1917 that Albert Einstein theorized the concept of “Stimulated Emission” that made today’s LASERs possible. Since then many scientist and companies have created LASERs for various cosmetic and medical purposes simply by altering the wavelenth and strength of the light.
It seems like new lasers hit the market on a monthly basis. Some are the result of years of sound research and capital expenditures by major reputable companies, and some are put together by two men in a garage! Yet they all promise the world. Great results. Low risk. Minimal downtime. Laser sales reps, backed by their company’s medical research “data,” attempt to prove that their laser is the best one on the market. So who is right and who is wrong? Which one is the best? There are too many lasers to individually list but the technology shared by them can be broken down quickly for review. For completeness’ sake, I will briefly discuss “laser-like devices” used in cosmetic surgery as well since patients and even some healthcare professionals frequently refer to such devices erroneously as “lasers.”
For every problem in facial plastic surgery there are numerous solutions. This usually means that there is no “gold standard” but rather each solution has its merits and its downsides. So the best way to approach any issue is to look at the various options and try to fit the treatment regimen (be it laser or not) to the problem and not the other way around!
So basically let’s look briefly at the non-laser “lasers” first! These are devices like Thermage, Titan, IPL (Intense Pulse Light), etc. The reason many patients think of these as “lasers” is that the machines often look like true lasers. And some doctors advertise them as such. One of the distinguishing features between true lasers and the other “lasers” is that a true laser targets a specific molecule in the body. For example, pigment molecules (melanin) are the target of lasers used in hair removal and water molecules are the targets of CO2 lasers. There are many more differences between lasers and these other devices than there are similarities.
Thermage is a radio frequency device (RF) that heats the deeper layers of skin in order to heat up and traumatize the tissue. Over the course of a few months, this tissue stimulation causes cells in your skin called fibroblasts to produce more collagen fibers, resulting in more dense collagen networks and tighter tissue. It ideally avoids traumatizing the outer layer of skin so it does not “resurface” the skin but rather tightens it. Titan is another similar device, although it uses infra-red technology (IR) to do the same thing deep in the subcutaneous area. Most surgeons agree that Thermage works slightly better than Titan. There are also other RF devices. Lumenis also possesses this technology in their higher-end laser platforms as a combination device. (Platforms are machines that do more than one thing either by using different hand pieces or by using programming, etc).
The RF and IR devices are advertised as being non-surgical facelifts. The fact is that they will never do what a facelift does. In fact, at best they have a result that is equal to 20-30% of what a surgical lift offers. And this best-case scenario is only evident in about a third of patients undergoing such treatments. So the upside is that you can have a modest tightening without surgery, down time or any major risks. The downside is that you may just be throwing your money out the window if you are one of the unlucky two thirds of patients who do not show significant results. In inexperienced hands, these devices can also cause tissue atrophy or wasting from too much heat trauma and fat loss. So I reserve these devices for patients who are either too sick medically to have surgery or truly do not need a surgical lift. This is also a good option for patients who cannot afford any down time due to work or social obligations or who are just afraid of surgery but still want something done. If patients have low expectations, then about a third will be pleasantly surprised and happy but these services should never be “pushed” or “sold” because of their unpredictability.
The other major class of “non laser Lasers” is the IPL or Intense Pulse Light, also known as photo rejuvenation. These devices do use light or photons but differ from lasers in that they are not a single wavelength and they are not coherent light. Basically this is a very strong flash lamp and with the aid of different filters can have different general targets and depths of penetration. IPL is commonly used for hyper-pigmentation, Rosacea and small vascular lesions as well as hair removal. Some of the older devices were quite dangerous and could burn patients easily. The newer devices have much more improved technology and safety profiles. Palomar is one of the leading IPL devices currently in use. Again, as in any procedure in medicine, the operator can give you a great result or he/she can burn and scar you. These device’s results are limited by the education and experience of the operator. Be aware that sometimes IPL is advertised to perform skin tightening and rejuvenation. This is not the major strength of these machines and it will be a waste of your money and time. Anecdotally, twenty percent of patients with acne do see improvement with IPL therapy. Typically any IPL treatment requires a series of treatments. It can be combined with other skin care routines. Patients using Retin-A prior to the IPL treatment may find that there skin is very sensitive to the treatments. On the other hand, some patients do benefit from skin sensitizers such as Levulan Kerastick (Aminolevulinic Acid).
Hair removal in all skin types is the newest feature of some of the IPL devices. They are generally less painful for hair removal than other devices. Isolaz is such an example. “Reveal Med-spas” that advertise pain free laser hair removal are in fact using IPL from Palomar.
As far as actual true lasers go, there are too many to mention. Just like there are too many companies making IPL to mention them all. In the past if you wanted a certain function as a doctor you had to purchase an individual laser. These ranged from $60,000 to over $200,000 per machine. As you can imagine, some doctors would buy one laser and when faced with the realities of “paying it off” would end up somehow finding a reason to use that individual laser on many of their patients! Others would purchase multiple machines to do multiple things such as treat wrinkles with a CO2 laser and treat birthmarks with a Pulsed Dye Laser and use a Diode laser or Alexandrite to remove unwanted hair, and so on. Not only was this expensive, each doctor’s office would end up looking like an appliance warehouse! Today, many of the available devices are sold as “platforms” such as Sciton, or Palomar. These are basically all-in-one machines that can be modified and expanded as needed. Some have functions that are not proven or truly beneficial but most have a combination of useful technologies. For example, Cynosure’s hair removal laser combines an Alexandrite for lighter skin types with a 1064-YAG which is safe in darker skinned patients.
So basically to choose “what’s the best laser” you have to ask “what am I trying to treat?” There are many options out there. For example, Pulsed Dye Lasers are the “gold standard” for vascular lesions, birthmarks, spider veins, etc. However, IPL technology has reached a point that it can offer a decent alternative to PDL units for a fraction of the cost of the machine. The more choices a doctor has and the more options and the less the laser cost him/her to purchase the better it is for the patient.
For resurfacing or wrinkle reduction the gold standard was the CO2 laser followed by the Erbium laser. MaxFX and ActiveFX are Lumenis’ method of delineating more aggressive and powerful CO2 lasers from lighter treatments. Recently the Fraxel laser came out offering an alternative with lower down time by using fractionated Erbium laser technology. This basically involved treating small zones and spearing others allowing quicker healing from these adjacent zones. As in any other technology, once available, others modify and copy or improved on it. Pixel laser is such an example which uses an Erbium-YAG laser. The newest versions of fractionated lasers are the fractionated CO2 lasers which are more aggressive with better results. Although Fraxel was the first on the market, these devices are now referred to as “fractionated” laser resurfacing devices since there are several available today. Similarly, when “SmartLipo” became available it was the only kid on the block but now several companies use this technology so the more appropriate terminology is laser-assisted liposuction. These devices use lasers to melt fat molecules and also treat the undersurface of the skin allowing modest to moderate fat reduction and tightening in the appropriate patients in the sub-mental area.
I could go on and on but by the time I finish this paragraph a new laser will have hit the market! The fact is there are many great lasers and devices and many more unproven ones. The larger companies create safer lasers and spend more money on research and development. Lasers are not the answer to all of our problems. A cold hard scalpel still makes a more accurate and defined cut resulting in better scars than any laser available due to the most minimal heat damage to the surrounding tissue edges. Just because Dr. A uses a laser is does not make his or her results better. Chemical peels and dermabrasion can often do as good a job or better than many lasers on the market today for resurfacing. Electrolysis is still a great option for very small areas and lighter hairs. Each laser should be looked at separately and each patient must be evaluated thoroughly and each complaint or problem should be approached from different view points. Finally, the operator is key. Some states have strict rules and regulations as to who can operate what laser and some states do not. As in anything in plastic surgery, buyer beware!
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About Dr. Naderi:
Dr. Naderi is a member of an exclusive & highly specialized group of Board Certified Facial Plastic Surgeons who have dedicated their surgical practice and expertise to helping those who are looking to improve their appearance and quality of life through nasal reshaping surgery (Rhinoplasty). This includes patients seeking “Primary Rhinoplasty” (nose job) as well as the unfortunate patients who have suffered from poor outcomes of previous improper nasal surgery (Revision Rhinoplasty or Secondary Rhinoplasty).
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