Lasers: A Lay Person`s Guide

Posted Wednesday, September 5, 2007 to PROCEDURES > Skin

Posted by The Original Anti-Aging & Cosmetic Surgery Magazine

Dermatologists Patrick Lee MD and Gary Lask MD explain the cosmetic used of modern lasers.

There has been a great deal of media attention paid in the last several years to the cosmetic applications of cutaneous laser surgery, such as that for wrinkles, scars, pigmentary disorders, leg veins, etc. However, much of this widespread information has been inaccurate and misleading, giving the public misconceptions and false expectations about what laser surgery can provide. This article will help to clarify some of these issues.

Laser is an acronym for Light Amplification by Stimulated Emission of Radiation. What this basically says is that lasers are devices that are able to harness energy from light beams and redirect them so that they produce very specific wavelengths of light, which then allow them to treat very specific conditions. The radiation that is produced by cutaneous lasers is non-ionizing radiation (unlike X-rays), so there are none of the associated dangers. However, cutaneous lasers are considered complex medical devices, meaning they can be dangerous in wrong or untrained hands, and must be used or supervised by a qualified medical practitioner. In addition, any ancillary personnel involved in the care of a patient treated with a cutaneous laser must observe and follow strict safety precautions, such as appropriate protective eyewear.

There are several types of cutaneous lasers available and each has specific conditions that it is designed to treat, ie, one laser is not appropriate for every condition. And a laser is usually named for the internal substance that gives it its specific wavelength and treatment properties; these substances are gas (eg carbon dioxide), liquid (eg dye) and solid (eg ruby). The conditions that cutaneous lasers are able to treat generally fall into four categories: resurfacing conditions such as wrinkles and scars; vascular lesions such as blood vessels and leg veins; pigmented lesions such as brown spots and tattoos; and, most recently, excess or unwanted hair.

LASER RESURFACING

Laser resurfacing is basically a controlled mechanical removal of skin. The laser selectively heats and vaporizes the superficial layers of skin. This procedure is usually performed on the face. It removes the superficial layers of skin, thus softening wrinkles and stimulating growth of new skin cells. There is also evidence that the temporary inflammation induced by the resurfacing may produce new fibers of collagen, the skin's support network, thus increasing the turgor and strength of the skin. Thus, the overall effect can be fresher, more supple and youthful-looking skin. Patients who can benefit from this procedure may have one or more of the following: wrinkling, dull or weathered skin, freckling or blotchy pigmentation, sun damage (including signs of pre-cancer), and shallow or saucer-shaped acne scars. Some conditions need deeper removal and penetration by the laser than others, which may then lengthen recovery time. Penetration too deeply could result in scarring and/or permanent pigmentary changes. It should be emphasized that in most cases, wrinkles and scars cannot be removed or eradicated; in the best scenarios, they are gently improved and their severity softened.

There are two types of lasers currently being used for laser resurfacing: the carbon dioxide (C02) laser and the erbium YAG laser.

The C02 laser has been used for the treatment of various conditions for more than 30 years. It emits an intense beam of light that heats and vaporizes water in skin tissue instantaneously. Its limitation in treating skin had always been the unwanted side effect of scarring. Recent advances in technology have allowed the carbon dioxide laser to be refined; it now works more precisely so the effect on normal surrounding tissue is minimized. However, one of the drawbacks of this laser in resurfacing has been the persistent redness of the skin pigment after treatment, sometimes lasting weeks to months, and more recently, loss of pigment in treated areas has become a more common occurrence.

The erbium YAG laser has been widely used for resurfacing in Europe, but has only gained more widespread use in the US recently. This laser's wavelength beam is absorbed by water in the skin with ten times the affinity of the CO2 laser, so the tissue removal is much more superficial, usually resulting in quicker healing time and less overall redness. In addition, areas that have a high potential for poor healing and excess scar formation with resurfacing, such as the hands and neck, may be more safely approached with the erbium YAG laser, although more long term results need to be obtained.

There are numerous C02 and erbium YAG lasers available from a variety of manufacturers. In the properly trained hands, all C02 lasers can yield equivalent results, and all erbium YAG lasers can yield equivalent results.

Benefits of C02 and erbium resurfacing include:

• Improvement in wrinkles
• Softening of scars
• Decrease in sun damage
• Outpatient procedure

VASCULAR LESIONS

There are numerous vascular or blood vessel lesions of the skin, but the most common ones amenable to laser treatment are telangiectasias (small blood vessels of the face), red stretch marks and scars, hemangiomas and portwine stains (benign vascular growths or birthmarks) and leg veins.

Telangiectasias of the face can be very easily treated with modern cutaneous lasers.The pulsed dye, copper vapor, copper bromide and KTP lasers are just a few that are available for treatment of these sometimes cosmetically bothersome lesions. Increased incidence of these blood vessels on the face are seen with long-term sun damage and medical conditions such as rosacea. These blood vessels are usually treated as an outpatient, no anesthesia is required, and often only one or two treatments are necessary. Scarring and textural skin changes are uncommon, particularly with the pulsed dye laser.

Stretch marks, which are basically atrophic scars, and other scars can improve with laser treatment if they have a vascular component, essentially redness. Laser reduction of the redness can sometimes affect the remodeling of the scars, often reducing their size and thickness. However, multiple treatments may be necessary.

Hemangiomas and portwine stains are birthmarks which can be emotionally distressing to young children and their parents, as well as many adult patients. Advances in vascular lasers have made treatment of some of these conditions much easier. Portwine stains, especially flat lesions, can respond very well to vascular laser treatment; in some cases, the skin can appear as if no lesion had been present at all. Treatment can be done as an outpatient, although with larger lesions and in children general anesthesia may be necessary. Multiple treatments are typical. Some capillary or small vessel hemangiomas, if treated early in infants and children, can have their growth limited by vascular laser treatment and sometimes early resolution can occur. Multiple treatments may be necessary.

Leg veins, until recently, were only treated effectively with injection sclerotherapy.But newer vascular lasers, such as the long pulse dye laser,have now become complementary treatments for leg veins. Certain patients, such as those who have leg veins resistant to sclerotherapy or who cannot tolerate needle injections, can receive vascular laser sessions as solo treatment, but most patients will need sclerotherapy as a primary treatment, and laser treatment only if necessary.If laser treatment of leg veins is done, multiple treatments are necessary.

Benefits of vascular laser treatment:

• Reduction/removal of blood vessels on the face
• Reduction of redness in stretch marks and scars
• Improvement of certain birthmarks such as hemangiomas and portwine stains
• Improvement of leg veins

BENIGN PIGMENTED LESIONS AND TATTOOS

Benign pigmented lesions include freckles and sun induced freckles ("liver spots") called solar lentigines, as well as some pigmented birthmarks such as cafe au- lait macules. These conditions can improve with pigment specific laser treatment. Melasma, a benign disorder of pigmentation seen on women's faces often secondary to hormones and sun, has not responded well to laser treatment; it is more appropriately treated with other measures such as bleaching compounds.

Pigment specific lasers include the Q-switched Nd:YAG, the Q-switched ruby, and the Q-switched alexandrite lasers. The "Q-switched" refers to Quality switching, a feature of these lasers that allows the beam to be shuttered very quickly, allowing large amounts of energy released in millionths of a second time. Pigment specific lasers have wavelengths that target melanin, which is the pigment that resides in our skin giving it color, and other outside pigments, such as those found in tattoos. Melanin is present in higher amounts in freckles and solar lentigines as well as cafe au- lait macules so they can respond well to pigment specific lasers, especially one of the two wavelengths available on the Nd:YAG laser. Multiple treatments may be necessary but these lasers are safe and scarring is very uncommon. Tattoos have various types of pigment in them and certain lasers work better for certain colors. The longer wavelength of the Nd:YAG laser treats blue black tattoo ink well, and its shorter wavelength can work on red ink. The ruby and alexandrite lasers can treat blue-black tattoos similarly, but can be more advantageous for green ink tattoos. Multiple treatments are always necessary. Scarring is very uncommon. Treatment is done as an outpatient and local anesthesia may be required.

Benefits of pigment specific lasers:

• Reduction/removal of benign pigmented lesions such as freckles and sun-induced freckles and pigmented birthmarks such as cafe-au-lait macules
• Improvement/lightening of tattoos

LASER HAIR REMOVAL

The newest development in cutaneous laser therapy has been treatment of excess and/or unwanted hair. Many of the available hair removal lasers are modifications of the pigment specific lasers, such as the long pulse ruby and long pulse alexandrite lasers. They have been modified to deliver energy to the pigment cells within the hair follicles, thus causing disruption of hair follicle activity and growth. Often one treatment causes only partial hair reduction, so multiple treatments may be necessary. Most areas of the body appear safe to treat.

One potential drawback of the hair removal systems is that pigmentary alteration can occur because of melanin presence in the skin. Therefore, the more ideal candidate is a fair-skinned, dark-haired patient. In addition, some systems have been developed to more specifically target hair pigment versus skin pigment, increasing the chances for better follicle disruption and less pigment alteration. This allows for the potential treatment of darker skinned patients, but lower energies are required - also treatment may not result in permanent hair reduction but only delayed hair growth.

Benefits of laser hair removal:

• Permanent hair reduction
• Less painful and tedious than waxing and electrolysis
• Ideal candidate fair skin, dark hair

CONCLUSION

Cutaneous laser therapy can give safe, effective treatment for a variety of conditions. The appropriate laser in the appropriate hands for the appropriate condition can yield impressive results, but both the physician and the patient must have realistic expectations.

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