Lasers - The Cutting Edge in Cosmetic Surgery – Part 1

By Lois W. Stern

I know exactly what you want, because I want it too: skin treatments that are less invasive, with little downtime, minimal risk and excellent, long lasting results! But this is not just a consumer ‘Wish List’. Plastic surgeons and dermatologists want to deliver skin treatments that meet those very same criteria. Popular interest in these magical ‘quick fixes’ is so huge that when Fraxel Re:pair recently debuted on the Today Show, the parent company, Reliant, had 20,000 hits on its website in 90 minutes, causing it to shut down. Given such strong public interest, Reliant was invited back on the Today Show a week later to further demonstrate its Fraxel lasers, and again their website was besieged by a deluge of visitors.

Will this new breed of lasers take the place of surgical facelifts? Will they ultimately give us similar, yet kinder, gentler results than the ablative resurfacing techniques of decades past?

Several manufacturers are scrambling to answer the call.

Dr. Lawrence Bass, Clinical Assistant Professor of Plastic Surgery and Director of the Minimally Invasive Plastic Surgery Program at New York University Medical Center,
has generously given of his time and expertise, to educate me about what is happening in the field of lasers. Now it is time for me to share with you, my readers, what I have learned.

The basic concept behind all laser technologies is the same: wound and heal. One must wound the skin to remove old surface tissue, which in turn stimulates the growth of new collagen.

Understanding the Anatomy of Our Skin

Stratum Corneum (the outermost surface of the Epidermis)

The outer layer of our skin is called the epidermis, with the stratum corneum its outermost surface. Beneath the epidermis lies the dermis. Fat cells lie beneath the dermis, within the subcutaneous layer. When one loses volume in the face, it is due to loss of fat in the subcutaneous layer.

Remodeling is one of our twenty-first century buzzwords. You might have noticed some home remodeling taking place within your neighborhood, but skin remodeling is just as popular. The difference is that this latter type remodeling works to rejuvenate the skin covering our bodies, rather than altering interior or exterior features of our homes. Dr. Bass has given me some further explanation:

“When we speak of remodeling for wrinkle treatments, we are targeting treatment within the mid-dermis. For skin-tightening devices (Titan, Thermage), we are targeting the deep dermis at the dermal/subcutaneous junction.”

The era of ablative resurfacing lasers began with Carbon dioxide lasers (CO2), which worked by vaporizing wrinkles and/or acne scars, while evening out hills and valleys on the surface of the skin. Old, damaged tissue was removed and new tissue remodeled. In other words, as these laser wounds began to heal, they stimulated the growth of new collagen through that process of wound healing, which is normally followed by the stimulation and growth of new collagen. Clinical results were excellent and surgeons found that these Carbon dioxide lasers provided more precision in depth control than the earlier method of chemical peels. The down side to these lasers was their lengthy recovery for the patient, who was left with a raw surface that healed slowly over a period of 10–14 days. Additionally, the skin remained red for 3–6 months or longer with a good risk of pigment disturbances, especially for those with darker complexions.

A second option was/is Erbium:YAG ablative resurfacing. It showed remodeling improvement in some respects, but generally showed a little less improvement than CO2 resurfacing. Er:YAG healing typically took 5–7 days with about one month of redness for a mid-intensity peel. An aggressive peel could approach the recovery time of a CO2 peel. A very light peel could heal in 3 days with about 5 days of redness. The Er:YAG is still used, especially by surgeons to resurface at the same time they are doing a facelift or eyelidplasty, as the patient can heal from resurfacing while recovering from the surgery. Stand alone wrinkle treatments have largely been replaced by fractional treatments.

A number of nonablative remodeling treatments arrived on the scene to try to avoid creating open wounds, lengthy recovery periods and the possible pigment discolorations associated with the above devices. Cooltouch, designed to produce tissue remodeling by heating mid layers of skin while keeping the skin surface intact, was one such example. But clinical response showed minimal and unpredictable results with treatments yielding no tissue removal and inconsistent amounts of skin remodeling. The big advantage was no recovery time and no real risk of pigment problem. But multiple treatments (an average of 4) were required and results were much less effective than those achieved through ablative laser resurfacing. The big disadvantage was “no pain, no gain”.

A new breed of fractional lasers keep arriving on the scene to respond to our needs. In my next article, I will be explaining the technology behind fractional lasers and what you can expect from these treatments.

© 2008 by Lois W. Stern

You can contact Lois at: cosmeticsurgery@optonline.net and she willl actually respond!

You have permission to reprint this article in part or full provided it contains the following attribution:

Lois W. Stern is the author of Sex, Lies and Cosmetic Surgery (Infinity 2006), soon to be republished in a new edition with a accompanying back-of-the-book CD. Visit her website at: http://www.cosmeticsurgery@optonline.com/ for “tons of valuable information” or to sign up for her monthly newsletter.