Through years of technological advancements today’s laser-based skin treatments offer users drastically better results and safety improvements. Lasers are now utilized for a variety of cosmetic dermatology treatments including removal of unwanted vessels or pigmentation, skin tightening, skin resurfacing, body contouring and smoothing, and tattoo or hair removal. Not all lasers are created equal; and each laser has its advantages and disadvantages. No laser is able to treat all aspects of our skin; so it is important to understand which laser is best for each area of concern.
Ablative Lasers
Ablative lasers were among the first laser types to be utilized for skin resurfacing. These devices use high energies to remove a portion of the top layer of the skin (epidermis). The removal of damaged skin allows the skin to replenish itself created smoother texture, increased collagen, and less signs of sun damage (pigmentation). Generally, these lasers are used to treat fine lines, sun damage, scarring (including acne scars), and pigmentation.
These devices generally require local anesthesia with or without oral analgesia (pain control). Historically, two different types of lasers have been used for ablating the skin: Carbon Dioxide (CO2) and Erbium-Yag. The older versions of these lasers had more potential for side-effects. Newer versions of these lasers utilize fractional technology where some skin is left intact. This allows for faster healing times and decreased side-effects.
For tissue ablation, we use the Fraxel RePair or Active Fx lasers. These treatments do have some downtime with a week of healing and a few weeks of redness of the skin that abates over time.
Non-ablative Resurfacing
Non-ablative resurfacing lasers were invented to attempt to get the same results of the ablative devices without the need for extended down time. These devices use wavelengths of light that penetrate deeper into the skin creating heating. The heat generated caused remodeling of the collagen layer of the skin (dermis). Like the ablative lasers, many of these devices use fractional technology where only a portion of the skin is treated at a given time to facilitate less downtime.
These devices tend to treat very similar conditions as the ablative devices such as skin texture, fine lines, scarring, stretch marks and pigmentation. The advantage with these devices is that there is minimal downtime usually only a day or two. However, these devices generally require more treatments to achieve optimal results (usually 4-6 treatments). There is less pain associated with these procedures; generally, only topical anesthesia is required.
Fraxel Dual is by far the most popular fractional non-ablative laser on the market today.
Vascular lasers
Vascular lasers use a specific wavelength of light to target unwanted blood vessels and redness (including red scars). These lasers create heating in only the targeted tissue leading to decreased appearance to small vessels on the face (telangiectasia), generalized redness (erythema), red scars (including hypertrophic), and the early stages of stretch marks(striae rubra). There are generally 2 types of lasers in this category: pulsed dye lasers and 532nm devices (KTP or frequency double Nd-Yag)
The Pulsed Dye Laser or PDL are the most common devices used to treat these conditions. The wavelength used is very specific for blood vessels; thus, there is less damage to surrounding structures. Current popular pulsed dye lasers on the marketing include V-Beam.
The 532nm devices tend to be more tunable and able to treat deeper vessels that the PDL; so these devices work better for larger vessels that usually appear to be purple rather than red. These devices can be used to treat leg veins as well; however, sclerotherapy is still the best option for treating veins on the legs. We currently use the Excel V laser in this category.
All of these devices tend to take multiple treatments to decrease the appearance of the targeted area. Patients are advised to avoid sun exposure for a few days afterward and to wear sunscreen. The areas treated may be more obvious after treatment and some mild swelling can occur.
Tattoo Lasers
Lasers that are used to treat tattoos are a specific group of lasers that deliver high amounts of energy very quickly to the target pigment. Because tattoo ink is a foreign to the body and mostly composed of metals, these lasers work by breaking the pigment into smaller sizes so that the body’s immune cells (macrophages) can get rid of it. Because of this, the intensity of the ink slowly lessens overtime after treatment for a period of a few months. The colors of the ink in the tattoo dictate what wavelength of laser needs to be used.
Traditional tattoo lasers are what are known as q-switched lasers. These devices deliver high energy over a period of a nanosecond (1 billionth of a second). Newer devices are able to deliver this energy even faster, and now picosecond (1 trillionth of a second) devices are the latest lasers to be used to treat tattoos. Picosecond lasers, such as the Picosure, are able to remove tattoos in about half the amount of treatments compared to the q-switched devices.
Treatments are generally done at least 4 weeks apart; however, it is better to wait 6-8 week to allow for more clearing of the ink. With all of these devices there is a small healing time where swelling and small blisters can occur; patients are advised to treat the area with emollients and cover the treated area for protection.
In addition to the above laser treatments there are a variety of non-laser devices with the ability to provide many of the same benefits.
Ultrasound Devices
Ultrasound technology is one of the latest sources of energy being utilized in cosmetic surgery. Ultrasound uses controlled sound waves to deliver energy to specific tissues in the body. The higher energy ultrasounds create heat as opposed to low energy ultrasound use in typical diagnostic settings. Focused ultrasound waves are able to be delivered to deep layers of the skin and even into the fat in order to have some cosmetic benefit.
Focused ultrasound that targets the tissue just under the skin surface (Dermis) is able to lift and tighten loose skin without cutting or disrupting the surface of the skin. Ultherapy is a non-invasive treatment that can firm, tighten and lift the skin of the face, neck, and décoletté. The ultrasound creates heat in the areas of the skin where collagen predominates. This heating causes weaker collagen to be turned over into newer / more robust collagen leading to better skin quality and tightening.
These treatments take about an hour and have no social downtime. During the treatment, patients do experience mild discomfort; many patients prefer to take an anti-anxiety medication prior to the treatment to help them relax. After the treatment, there may be some mild soreness to the touch for a few days. Results from these treatments are delayed with best results at 3-4 months; however, most patients begin seeing improvement in about a month.
Focuses ultrasound can also be used to treat excess fat. Ultrashape is a recently approved device that is able to target subcutaneous fat and decrease inches. This device uses ultrasound to shake fat cells apart (cavitation) which causes the fat cells to die. The fat is then removed from the area by the lymphatic system. During the treatment there is generally no discomfort (only a mild warming sensation). Typically, treatments take about 45 minutes and are performed about 2 weeks apart. There is no downtime and no post-treatment restrictions.
Radiofrequency (RF)
Similar to ultrasound, radiofrequency is a source of energy that can deliver heat to targeted layers below the dermis without damaging the top layer of the skin.
Today’s most popular radiofrequency based treatment is Thermage. Thermage treatments generally take about an hour to do. There is some mild discomfort during the procedure. Like, Ulthera there is no social downtime; also, because the treatment relies on the production of new collagen, the results are delayed with full results in 3-4 months. Thermage is indicated for multiple areas of the body. There are currently treatment tips for tightening of the face, body, cellulite, and even the eyelids. Generally, 2 treatments are needed to achieve expected results.
IPL
Intense Pulsed Light (IPL) acts like a laser but instead uses multiple wavelengths of light to treat facial redness and improve sun-damaged skin. IPL is able to treat vessels of the face, redness of the face and neck, rosacea, sun-spots (lentigines), and overall skin texture.
Typically, treatments take about 30 minutes; prior to treatment, a topical anesthetic is usually applied for about 15-30 minutes. During the treatment, there is some mild discomfort that is tolerable with the topical anesthesia. After the treatment, patients need to be aware that they may be swollen or red for 2-3 days. There can even be a mild peeling that if often referred to as peppering. Patients are advised to avoid direct sun exposure and heavy exercise during the healing period. Treatments are performed monthly with most patients needing 3-4 treatments for optimal results.
