5) Removing Wrinkles with Lasers: Novel Skin Tighteners

Although some in the fourth class of skin tighteners are not actually lasers, I have grouped...

radiofrequency devices

and

infrared lasers

together because they function similarly:

• deep tissue heating
• subsequent collagen production
• subsequent tightening
• with a goal of creating true lifting without surgery
• but uniformly falling very short relative to surgical facelifting or traditional (15-year-old) ablative laser technology

Radiofrequency devices are like microwaves.  They emit low-frequency light energy (radio waves and microwaves) to create heat in deeper tissues.  The most popular in this new class is the Thermage....

• Advantages:
  • minimal post-procedure redness
  • minimal side effects
• Disadvantages:
  • quite uncomfortable during the treatment
  • inconsistency of results
    • about 1/3 will have significant improvement--but only after waiting months for full collagen production and tightening
    • the other 2/3 will obtain minimal if any improvement, no matter how long they wait
    • In at least one study, only 5 of 15 Thermage patients reported satisfactory results, and the photographic analysis by experts did not yield any statistically significant results.
• Recent modifications may have improved the technology.  The final verdict is still out.

Infrared devices also produce deep penetration.  A popular model is the Titan.

• Advantages:
  • safe
  • not much downtime
  • not too uncomfortable
• Disadvantages:
  • poorly studied--even worse research than for Thermage
  • absolutely no long-term research
  • At least one preliminary study showed less improvement with an infrared device compared to a radiofrequency device.  (And, as mentioned above, radiofrequency devices are, at best, minimally effective.  So, this is a pretty damning comparison.)

Combinations devices may produce augmented effects relative to either radiofrequency or infrared alone.  The Galaxy is the most well known combination device.

• Combination of...
  • bipolar radiofrequency
  • infrared laser
  • intense pulsed light
• Advantages:
  • apparently safe
  • minimal downtime
  • radiofrequency and infrared energies may be synergistic to produce real improvements
• Disadvantages:
  • The radiofrequency portion of the treatment may hurt (like Thermage).
  • the least well studied of all
  • almost no good quality research documenting efficacy
  • almost no long-term research

The bottom line:  I don't own a radiofrequency device, an infrared laser, or a combination machine.  And I don't plan to buy one any time soon.  The non-surgical facelift remains elusive.

However, skin tightening using radiofrequency or infrared energy sources is a compelling area of active research.  I think that it is worth my time to keep abreast of this technology.  As newer, more effective devices are rapidly becoming available, the objective of achieving the non-surgical face lift may become a reality during my career.

4) Removing Wrinkles with Lasers: Fractionated Lasers

By the mid aughts (about 6-7 years ago), patients who were interested in removing fine facial wrinkles were facing a dilemma....

• If they chose an ablative laser treatment, they would destroy the top layers of skin, which would produce dramatic results.  But their recovery would be prolonged, and there would be risks of complications.
• However, if they opted for non-ablative/lunchtime lasers, they would only minimally heat the top layers of their facial skin.  Without a deep burn, the downtime would be minimal, but so would be the results.

Clever doctors thought of ways to combine the advantages of ablative lasers (good wrinkle reduction) with the advantages of the lunchtime lasers (minimal downtime).  How about using a truly ablative laser, but just on a fraction of the skin?

Like a microscopic checkerboard, a fractionated laser destroys a portion of the skin's top layers, but leaves neighboring tissue (microns away) uninjured.  The undamaged surrounding tissue allows for a reservoir of viable tissue, permitting rapid epidermal repair.

Fractionated lasers are "in between" lasers for removing wrinkles.

• Some wrinkle reduction
• Some improvement in acne scarring
• Some skin tightening
• Some exfoliation
• Some downtime
• Some risks of complications 

I don't own a fractionated laser because this technology is evolving so rapidly.  In particular,

• I distinguish between fractionated erbium lasers and fractionated CO2 lasers.
• The fractionated erbium machines are pretty unimpressive.
  • For the pain and expense, my patients have been dissatisfied.
  • I no longer offer fractionated erbium lasers in my practice.
• However, the fractionated CO2 lasers are interesting.
  • Relatively new, this sub-class of lasers may be the best answer for many patients.
  • Unfortunately, this technology is so new that there are not good data regarding long-term efficacy.
  • Fractionated CO2 lasers are the sub-class to keep an eye on.  They may be the future.

3) Removing Wrinkles with Lasers: Lunchtime Lasers

Because of prolonged recovery times and potentials for complications, ablative lasers have never become extremely popular, despite their dramatic results.  On the other hand, non-ablative ("lunchtime") lasers have become much more widespread because they are simple....

• no significant damage to the surface of the skin
  • virtually no recovery time
• just 1st-degree burns (or less)
  • like a sunburn
  • the skin feels a little hot and a bit uncomfortable
  • easily soothed with moisturizers (such as aloe vera)
  • any pain is controlled with plain Tylenol
  • safe to apply make-up immediately after a treatment
• no 2nd-degree burning
  • therefore, no raw, weeping surfaces
  • no looking scary
  • no reason to stay hidden in your house for weeks
• no operating room
  • safe to use in the office
• no anesthesiologist
  • no going to sleep
  • no IVs
  • no waking up nauseous
  • just numbing creams and ice to diminish the minimal pain

Since non-ablative lasers are so safe and have such limited morbidity, patients can easily come in for a treatment over their lunch hour--hence, the name, lunchtime lasers.

But you get what you pay for!

If you "pay" with general anesthesia, raw skin, and weeks of recovery, then you get a dramatic result (ablative lasers).  However, if you don't get a deep burn, then..

• you don't stimulate much new collagen
• you don't erase many wrinkles
• you don't soften many acne scars
• you don't get much tightening

Check out these before and after photos:



Frankly, the limited improvement that you see in the wrinkles is probably due to some post-procedure swelling.  Long-term, wrinkles are reduced very little.

But you should notice significant improvement in blemishes and in skin quality.  I have a lunchtime laser in my office, and I like it for...

• lightening blemishes and brown spots
• decreasing pore size
• generally improving the tone and texture of the skin.

I sometimes read other plastic surgeons' blogs and advertisements which state that non-ablative lasers necessitate multiple treatments to reduce wrinkles even close to the effects of an ablative laser.  Actually, those plastic surgeons are being too generous!  I would argue that, when considering wrinkle removal, the results of nonablative lasers NEVER come close to the results of the ablative lasers, no matter how many treatments a patient undergoes.

Lunchtime lasers do have a place in plastic surgery.  Just not for wrinkle removal.

2) Removing Wrinkles with Lasers: Ablative Lasers

Fine wrinkles typically don't respond well to surgery.  While a facelift can elevate and recontour the cheeks, jaw line, and neck, the "etched in" wrinkles on the cheeks and around the mouth are not significantly softened.

Some of those wrinkles can be filled, such as with Restylane, Juvederm, Radiesse, or Sculptra.  However many respond best to resurfacing.

Skin resurfacing refers to controlled burning of the top layers of the skin.  Subsequent healing produces new collagen, tightening, and smoothing.

When the heat is high enough to destroy those top layers of skin, plastic surgeons say that the resurfacing has been ablative.

Ablative resurfacing is the best way to...

• diminish fine wrinkles, especially around the eyelids and mouth
• remove blemishes and age spots
• soften acne scars
• uniformly tighten facial skin

There are a variety of technologies to ablate and thereby resurface aging skin....

• Mechanical dermabrasion
  • with a high-speed diamond burr
  • effectively, the surgeon is "sanding off" the top layers of skin
• Chemical peels
  • with tricholoracetic acid (TCA) or
  • with phenol-croton oil (Baker-Gordon formula)
  • in essence, the surgeon is using chemicals and acids to burn the top layers of the skin
• Ablative lasers
  • Carbon dioxide (CO2) lasers
  • Erbium lasers

Since their development in the 1990s, ablative lasers have gradually replaced mechanical dermabrasion and chemical peels as the treatments of choice for ablative resurfacing.  Lasers offer greater precision and a higher safety profile, and they have remained the gold standard for the past 20 years.

The results can be impressive.  Check out these photos:  immediately before a CO2 laser treatment, and 3-months after the procedure....

Note...

• softening of wrinkles at the eyelids, cheeks, and mouth
• significantly attenuated acne scarring
• generalized tightening
• healthier, more youthful appearance

With such such great results, why then don't you hear more about ablative laser resurfacing?

• It's real surgery.
  • Unlike "lunchtime" lasers, ablative lasers are not typically performed in the office.
  • For maximum safety, I use a fully accredited operating room.
  • For patient comfort, I insist upon general anesthesia.
• The recovery is prolonged.
  • Removing the top layers of skin effectively creates superficial 2nd-degree burns.
  • The healing skin will be raw and weepy for 3-14 days.
    • If the patient wants a subtle result, 3-7 days;
    • if she wants a more dramatic result, expect 10-14 days.
  • During that initial healing period, patients are very reluctant to leave their homes.  They can look pretty scary.  Many patients feel "shut in."
  • The above patient did not feel comfortable leaving her home for 1 month.  She absolutely loves her result, and she has told me many times that she would do it again, but she found the prolonged nature of healing to be emotionally difficult.
• The skin can lose its color, and can look waxy.
  • Darker-skinned patients may lose some of their pigment; think Michael Jackson.  Ablative resurfacing should be undertaken only with great caution in darker-skinned Hispanics, Asians, and Blacks.
  • Lighter-skinned patients usually fare better.  They have already been bleached by God, so there is no more pigment to be removed!
  • A pinkish blush can persist for 4-6 months after the laser.  Notice that, in the after photo, my patient's skin is a bit pink.  Partially, this is because she has a base of pink to her facial skin.  And, partially, the pinkness is the result of my poor photography skills; the lighting and exposure are somewhat different.  However, to a great degree, that pinkness is real.  It will probably persist for another 3 months (for about 6 months total), but may linger for longer or even forever.

I do love my CO2 laser.  As mentioned before, it remains the gold standard for skin resurfacing.  But be cautious when consulting about skin resurfacing.  More than any other type of laser, I would not recommend that you undergo ablative resurfacing at any local medispa.  As mentioned above, CO2 and erbium lasers create real burns.  Your post-operative care is similar to burn care.  Make sure that your doctor is trained to take care of burn injuries; go to a Board Certified Plastic Surgeon.  The potential for complications is high, and you need follow-up with an experienced doctor.  With ablative laser resurfacing, the procedure is straightforward, but the aftercare can be tricky.  Go to an expert; do not try to save a few bucks.

1) Removing Wrinkles with Lasers: An Introduction

Lasers are a cool technology in search of a use.

-James Sanger, M.D., 2001

Dr. Sanger was one of my professors during my plastic surgery residency.  While his cynicism was not unfounded in 2001, I do think that lasers are valuable tools in plastic surgery in 2011.

Why?  Because lasers remain the safest and most precise way to get rid of fine facial wrinkles.

Lasers work by focusing energy on particular colors.

• If you want to zap a red capillary, then choose a pulse-dye laser.
• If you want to get rid of a brown age spot, pick up a YAG laser.
• If you want to remove a multicolored tattoo, then you'll need a suite of devices to obliterate the individual pigments.

Focusing on a particular color produces selectivity--photoselectivity.  The color absorbs the specific laser energy.  Heat is generated.  The subsequent burn destroys the pigment, hopefully without damaging the surrounding, non-targeted tissues.

The lasers that purport to remove wrinkles do so by heating the upper layers of skin.  Effectively, they create controlled burns from the top down.  The resultant healing produces tightening and smoothing.

To a great degree, the result is dependent upon how much of a burn the patient is willing to tolerate.

• If she is willing to undergo general anesthesia and to hide away for a month, then a deep laser-brasion can produce a dramatic rejuvenation.
• But most patients would prefer to avoid "going to sleep."  And most don't have a month to spare.  Many don't even have a weekend off!  As such, "non-ablative" lasers have been developed that produce no more than a sunburn, in order to minimize downtime.  The negative is that the corresponding result is much less dramatic.

The biggest problem for the casual patient is the laser marketing.  The advertising is so compelling that it's hard even for me to keep track of which product does what.  What's true?  What's unfounded assertion?

In the next 4 articles in this series, we'll discuss the big picture.  I'll divide the rejuvenative lasers into 4 different categories, and I'll discuss the relative strengths and weaknesses of the classes of lasers....

1. Traditional ablative
2. Non-ablative ("lunchtime" lasers)
3. Fractionated ablative
4. Novel skin tighteners

Botox for Acne?

For the past decade, Botox (and now Dysport too) has been the primary wrinkle cure for smoothing the forehead and erasing crow's feet.  Less well known are its established uses in...

• reshaping the eyebrows, especially increasing the arching of the brows
• getting rid of "bunny lines" on the sides of the nose
• lifting the corners of the mouth (to soften sad frowns)
• diminishing the banding of the neck muscles
• minimizing sweating in the arm pits, hands, and feet

And now one report published in the Journal of Drugs in Dermatology suggests that Botox can effectively treat acne.  17 of 20 patients treated with Botox into the skin noticed that...

• their skin was less oily
• their pores were smaller
• their acne improved

I am excited to offer this option to my patients in Ventura, especially for those who have not had success with benzoyl peroxide, antibiotics, salicylic acid, light therapy, Accutane, and other types of acne treatments.

Package Deals in Plastic Surgery: Why They Make Sense

I have increasingly seen advertisements for plastic surgery "packages":

• New mommy makeovers:
  • Breast enhancement
  • Tummy tuck
  • Liposuction

• Surgical facial rejuvenation:
  • Browlift
  • Eyelids
  • Facelift
  • Necklift

• Non-surgical anti-aging:
  • Fotofacial/intense pulsed light lasers
  • Botox or Dysport
  • Fillers (like Juvederm, Restylane, Radiesse, or Sculptra)

My wife has been skeptical.  "Aren't those packages just gimmicks to sell additional services?"

Yes, but that's a good thing.  These bundled procedures do work well together.  Combining services can lead to results that are greater than the sum of their individual parts.

Consider the "new mommy makeover."  All women know that pregnancies and breast feeding cause both the breasts and the abdomen to swell.  In many women, the skin never snaps back to its pre-pregnancy elasticity.  Lifting or augmenting the breasts makes the chest look great.  However, the whole torso is not balanced until the tummy is also flattened and tightened.  So, combining breast enhancement with a tummy tuck does produce the best proportions.

Non-surgical solutions can also be performed concurrently to optimize results.  For example, the "11's" between the eyebrows will usually respond to Botox or Dysport; a 60-80% improvement is typical.  However, for some patients, 60-80% is not good enough; they want 90% erasure of the wrinkle.  So, adding a little bit of filler beneath the relaxed wrinkles (such as with Restylane or Juvederm) can nearly eradicate the 11's.

Fillers can even be used to enhance a surgery.  Everybody knows that a face/neck lift can improve the cheeks, jowls, jaw line, and neckline.  However, the area around the mouth is usually not rejuvenated.  So, I will often recommend Restylane or Juvederm to minimize the "smoker's lines" radiating from the lips.  Combining these fillers with the face/neck lift can produce the most harmonious result.

The 5-Finger Solution for Aging Hands in Ventura County

Practicing in Ventura, Oxnard, and Camarillo, in Southern California, I have many patients who have been sun worshippers.  Botox, soft-tissue fillers, lasers, and facelifts have rejuvenated their faces, but many women are concerned that their hands "still give me away."

My "5-Finger" solution for aging hands:

• Radiesse:  Calcium hydroxylapatite, better known as Radiesse, is a safe way to plump up the backs of your hands.  It fills the tissue beneath the skin, thereby hiding tendons and veins.

• IPL:  Intense Pulsed Light treatments are like lasers.  They remove freckles and age spots, while improving the texture of the skin.

• Moisturizer:  Dry, cracked skin itself looks old.  Hydrating the skin with a good moisturizer refreshes and rejuvenates the skin.

• Sunscreen:  At least SPF 30!  Prevent any more damage by wearing sunscreen all the time--even when you are not intending to be outside.  (It's amazing how much sun you get just by driving around town and by walking to and from your car between errands.)

• Readjust when you "play" outside:  I certainly don't want to ruin your good times.  Lord knows that we could all use more exercise.  However, try to avoid being in the sun when its rays are strongest--between 10 am and 3 pm.  Of course, when you go for your morning run or when you are playing in that afternoon softball game, don't forget your sunscreen.

Cosmoceutical Industry Hit Hard by Recession, Part 2: The Portrait Plasma is Gone

The second recent bankruptcy of a major cosmetic-medicine corporation is that of Rhytec (based in Massachusetts), which never sold enough of its Portrait Plasma devices.

The Portrait Plasma rejuvenated the skin with innovative technology.  Rather than heating the skin with a laser, it used plasma--the so-called fourth phase of matter (along with solids, liquids, and gases).

I never used this device, but it did generate a lot of positive buzz.  Supposedly, the results were at least equivalent to the Fraxel re:pair, but perhaps less plagued by depigmentation and color changes.

The Rhytec bankruptcy has left many Portrait Plasma owners scrambling for a source of the disposable nozzles necessary to deliver the plasma energy.  Since the British parent company has remained standing (at least for now), there is a chance that more nozzles may be available in the future.  However, if I were a patient in the middle of a series of treatments, I wouldn't delay my schedule!