Laser And Other Procedures - Skin Rejuvenation Procedures: Skin Health

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Laser and other procedures

Improvements in laser technology have sparked a revolution in the treatment of photoaged skin. Lasers remove moderate to deep lines and wrinkles while significantly improving skin tone, texture, and tightness. Their ability to target very specific types of cells in distinct skin layers enables them to treat conditions that were previously impossible to treat, such as port-wine stains, pigmented birth marks, and spider veins. They can also erase acne pits and many other scars.

Laser procedures are bloodless and can be controlled precisely, reducing the risk for injury or scarring. Recovery times for laser procedures vary depending on the individual and the depth of treatment. Although newer, less invasive treatments have little or no recovery time, repeat visits are usually necessary to achieve the best results.

Lasers work by emitting intense beams of bright "light" that transfer high levels of energy to a target in or on the skin. There, the energy is converted to heat. Lasers literally vaporize skin cells by heating up the water or pigments in the cells. Each laser produces a specific single wavelength, or color, of light — from the invisible infrared to visible reds, yellows, and greens. A laser's wavelength influences how deeply it penetrates the skin and how it will affect the skin. Because different wavelengths work on different problems, your physician will select the one that will treat your specific condition. For example, yellow and green wavelengths target the red pigments of port-wine stains, while infrared lasers are typically used to remove wrinkles, fine lines, and crow's feet.

Lasers also vary by the duration of their pulses. The duration of the pulse of light determines how a laser affects targeted tissue. A highly focused, continuous beam cuts through skin like a scalpel, but almost all cosmetic procedures require lasers that emit pulsed light, which confers the precise control needed to vaporize the intended skin layers or pigments.

The oldest type of laser treatment is ablative laser resurfacing. It triggers the skin's wound-healing response, promoting new collagen growth and leaving you with fresh, smooth skin. The skin also tightens, which is why laser resurfacing can act as a surrogate mini-facelift. Ablative laser resurfacing is most effective against damage to the epidermis and superficial layers of the dermis, including lines and wrinkles from sun damage, acne scars, actinic keratosis, freckles, liver spots, and dull patches caused by photodamage. Laser resurfacing may not be able to remove very deep lines and wrinkles; for those, you may need soft-tissue augmentation.

Over the last several years, newer, less invasive procedures have become popular because they achieve significant results with little or no recovery time. They include fractional resurfacing, plasma skin regeneration, and nonablative laser treatments. All of these techniques can treat fine lines, wrinkles, and scars, but the degree of improvement is greater with fractional resurfacing and plasma skin regeneration than with nonablative laser treatments.

How lasers work

Back in 1917, lasers were but a gleam in Albert Einstein's eye. His work "On the Quantum Theory of Radiation" laid the foundation for the development of lasers that decades later would be used in clinical applications. In dermatology, lasers came into use in the early 1960s. Laser procedures increased in the 1970s, with the introduction of lasers that could treat vascular marks such as port wine stains. But although lasers successfully faded these red discolorations, a risk of scarring existed. Since then, an array of technological improvements has produced much more precise lasers that can target specific areas within the skin without damaging the surrounding tissues and remodel the collagen without residual scarring. Today, some lasers are computer-controlled for optimum precision.

The word laser is short for "light amplification by stimulated emission of radiation." To produce their intense beams of bright light, lasers have to generate electrons. Some use gases to do this, while others use a solid or an organic dye. When the electrons are bombarded with energy from an outside source like an electrical current, they produce an intense beam that exits the chamber through a fiber-optic cable. The choice of gas, liquid, or solid will determine what wavelength of light the laser emits, and that will determine how the laser will be used.

The techniques described in this section may be used alone, but increasingly they are used in combination or with other cosmetic techniques to treat deeper wrinkles or scars on one area of the face, and finer lines or superficial lesions on another. Botox treatments and soft-tissue augmentation also are being used with laser resurfacing to get the most effective results in wrinkle reduction.

Ablative laser resurfacing

While once the only laser treatment for skin rejuvenation, ablative laser resurfacing is now reserved for advanced photodamage and severe acne scars. The carbon dioxide (CO₂) and erbium:YAG lasers are most commonly used. Both lasers generate invisible infrared wavelengths that are absorbed by the water in skin cells. Because skin consists largely of water, the laser strips away superficial layers of skin, removing lines and wrinkles from sun damage and facial expressions. While the lasers share some features, there are differences as well, and your physician will determine which type of laser will work best for your skin type.

The CO₂ laser penetrates more deeply than the erbium laser and vaporizes a thicker slice of skin — the entire epidermis. It also creates more thermal damage in the dermis, so it produces the most dramatic results in erasing deep lines and wrinkles. In addition, it can tighten the skin significantly. The intense heat of the CO₂ laser is painful, but you'll receive a local anesthetic to blunt the pain. Because this laser sometimes lightens skin, it requires extra caution when treating people with olive-colored or dark skin.

The erbium laser generates less heat and removes a thinner skin layer on one pass. Because the erbium laser penetrates the skin only about one-fifth as deeply as the CO₂ laser, it is usually selected for treating less severe lines and wrinkles. With one or two passes, the erbium laser moderately improves severe photoaging and eliminates many wrinkles. But your doctor can also make multiple passes to achieve the same dramatic results as with the CO₂ laser.

The erbium laser has a number of advantages over the CO₂ laser: It causes less pain during the procedure, requires less sedation and anesthesia, has fewer side effects, and requires half the recovery time. In addition, it's less likely to lighten the skin, so it may be safer on olive and dark skin.

There are some drawbacks to the erbium laser, though. The erbium laser doesn't seal blood vessels completely, so the skin oozes more. Also, it doesn't cause quite the same amount of thermal damage in the dermis as the CO₂ laser, so it may not induce as much skin tightening.

One trend is combination therapy, which involves using both types of lasers during a treatment. For example, to remove moderate to deep lines and wrinkles, the physician makes two passes with the CO₂ laser and a final pass with the erbium laser. This approach draws on the strengths of each laser while minimizing side effects: Patients may get better results than with the erbium laser alone and quicker healing and less redness than if only a CO₂ laser was used.

Another new approach is to get the effect of combination therapy by using a single tool, a dual-mode erbium:YAG laser. This laser works like a traditional erbium laser, but has properties that make it quite similar to the CO₂ laser as well. It can emit longer pulses as well as short ones, meaning the light stays on for a greater amount of time and heats the dermis to a degree equivalent to the CO₂ laser. So the physician can use the longer-pulsed mode for two passes and then switch to the shorter pulses for the final pass. By using both modes sequentially, he or she can get results similar to those derived from using the CO₂ and erbium lasers in combination.

The CO2 laser penetrates deeply into the skin and is able to tighten the skin significantly, eliminating deep lines and wrinkles. Because the heat from this laser is intense, patients receive a local anesthetic during the procedure. Recovery time is significant, but results usually last for several years.

How ablative laser resurfacing is done. Laser resurfacing is usually performed in your physician's office or a surgical suite, and it may take two or more hours, depending on what you are having done. You may have your entire face treated or just a trouble spot. Before the procedure, your doctor will prescribe antibiotic and antiviral medicines to reduce the risk of skin infections, as well as pain medication for afterward. You should avoid medications and supplements that may increase bleeding, including aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve), and vitamin E.

During the procedure, all people in the room — including you — will wear goggles to protect their eyes from the laser's intense light. Your skin will be cleaned. You'll remain conscious, but you'll have twilight sedation to minimize your anxiety and discomfort. Your doctor may also apply a topical anesthetic cream or give you local anesthesia to further numb the area for the procedure.

The laser itself consists of a handheld wand and various adjustable dials. Your doctor will move the wand over the treatment area as it emits beams of light.

After the procedure, your skin will need to recover. If you've had a CO₂ procedure, plan on taking two full weeks off work and social engagements; for an erbium laser treatment, plan on one week. Your doctor may apply a dense ointment to your face, but more commonly you'll wear a bandage for three days to keep the skin moist. The skin heals more quickly and evenly if it stays moist. You may need pain medication to reduce the throbbing that's common after laser resurfacing.

After you remove the bandage, using cool compresses for 20 to 30 minutes every few hours and applying a thick, moisturizing ointment can help relieve pain and speed healing. If a crust forms, roll a cotton swab over the area to remove it. Within two weeks, the wounds will heal. You'll still look like you have a bad sunburn, but many people feel ready to go out in public at this time. It's a good idea to curtail aerobic and other strenuous activity while the redness remains. Depending on your complexion, your skin may stay slightly red for two to six months. Your doctor will let you know when you can wear water-based makeup to cover the redness.

Your skin will look and feel remarkably smooth and wrinkle-free as soon as it heals, and it will continue to improve for three to six months. Results from one treatment should last for many years. Of course, laugh lines and other wrinkles caused by facial expressions will eventually recur with time, and wrinkles will develop as you age. Some people get Botox injections to prevent new expression lines from forming. If your laser resurfacing removed acne scars, you'll enjoy lifelong benefits.

Because sun damage can take years to appear, you may develop spots triggered by previous sun damage. You'll need to be extremely careful to prevent sun exposure, which can discolor areas of the skin.

With a skilled doctor, the risk of scarring is very low, but some people have permanently lightened skin. This complication is less common with the erbium laser than with the CO₂ laser.

Costs vary, but they may start around $2,700 for a portion of the face and $8,000 for the full face.

Fractional resurfacing

This innovative technique uses a device called a fractional laser to treat fine lines, wrinkles, sun spots, age spots, and other kinds of sun damage, as well as acne and surgical scars. Fractional laser energy is more precisely targeted than other ablative lasers — it produces microscopic columns of thermal damage, leaving the surrounding skin cells intact. While fractional resurfacing doesn't bring about the same degree of improvement as conventional laser resurfacing, it is becoming an attractive alternative because it demands little downtime.

Experts usually recommend three to five treatments, often spaced a week to a month apart. Treatments require only topical anesthesia to control pain. The skin is usually red for five to seven days following a treatment, and you may have mild swelling for a couple of days. Reduction of wrinkles and improvement in skin texture, pigmentation, and tightness may be seen almost immediately, but the results are progressive, with the best results appearing in about two to three months.

In addition to the face, fractional resurfacing can be used to treat other areas of the body, including the neck, chest, arms, and abdomen. The cost is about $1,500 for a full-face treatment and $1,000 for the neck. Many doctors offer price reductions for treating more than one area at once.

Plasma skin regeneration

This is a nonlaser technique that diminishes fine lines and wrinkles, including those around the eyes, as well as brown spots and other signs of sun damage. It also improves skin tone. Its effectiveness is comparable to that of fractional resurfacing.

Plasma skin regeneration uses a machine that emits a stream of plasma (ionized nitrogen gas) to heat the skin. The plasma has a lilac glow that changes to a yellow light. Like the ablative laser resurfacing, it superficially wounds the skin to improve its appearance. The plasma heats the skin either on the surface or deeper, depending on the need. The treated skin dries and comes off in three or four days, revealing fresh new skin. There's no oozing or crusting during recovery. The improvements increase for a year following treatment.

Plasma skin regeneration can be done in one high-energy treatment, which penetrates to layers beneath the surface of the skin, or in one or more low-energy treatments, which penetrate the surface layers. The cost is about $4,000 to $6,000 for the high-energy treatment and about $1,500 for each low-energy treatment.

Non-ablative laser resurfacing

Unlike ablative laser resurfacing, which is most effective against damage to the epidermis and superficial layers of the dermis, non-ablative laser resurfacing penetrates deep into the dermis while leaving the surface of the skin intact. It can treat scars and wrinkles, as well as moderate photodamage of the dermis. But because it doesn't alter the outer layers of the skin, it has no effect on discoloration or freckles caused by sun exposure. Non-ablative lasers work by shoring up collagen levels and stimulating new skin cell growth in the dermis.

The most commonly used non-ablative lasers are the SmoothBeam laser (1,450 nanometer diode laser) and the CoolTouch laser (1320 nanometer neodymium:YAG laser). Your doctor will choose one depending on his or her preference or the type of machine available. Both lasers emit invisible infrared wavelengths that penetrate beneath the epidermis, while spraying a cooling cryogen liquid on the skin to reduce surface damage.

While non-ablative laser treatments don't require the lengthy recovery time of laser resurfacing, the treatments themselves, which last 15 to 30 minutes, are painful. Before starting the procedure, your doctor may apply a topical anesthetic cream to your face to numb it. The cooling spray also helps.

Your skin may be red for an hour or two after treatment. But you can generally cover this redness with makeup, and there is usually no recovery time. Occasional complications include lightened or darkened skin, very mild skin pitting, and small, superficial blisters.

You'll need four to six treatments to get the full benefit. Costs vary, ranging from about $400 to $600 per treatment for the face. Many physicians offer package prices for the series. Some people get touch-ups yearly, but others find that the results last many years. You will see improvement after two or three treatments, and improvements may continue for a year or more. Because collagen grows slowly, changes happen gradually over time, and you may not notice them until you look at photos of yourself from months earlier.

Lasers for pigmentation, hair removal, and other problems

Lasers aren't used only for skin resurfacing. They can correct a variety of specific problems, too, including port-wine stains, red cheeks and noses, dilated blood vessels, spider veins, liver spots, and freckles. They are also used for removing tattoos and hair. In these cases, your doctor will use a different kind of laser than for skin resurfacing. The type of laser selected depends on the problem, particularly the color of the spots or pigmented areas to be removed.

Red spots, dilated blood vessels, spider veins, and broken capillaries require lasers that target the red pigments in hemoglobin, a component in blood, to eliminate these imperfections. Pulsed-dye lasers, which emit a yellow light, target these reddish pigments. These lasers are also used for minimizing wrinkles and increasing collagen and elastin in the skin. Side effects include swelling for a day and sometimes bruising. Potassium titanyl phosphate (KTP) lasers, which emit green light, can also treat broken capillaries. Treatments produce very mild redness or puffiness.

For brown pigment such as age spots, freckles, and some permanent makeup lines and tattoos, your doctor will use a Q-switched laser. Q-switched lasers, which emit very short, high-energy pulses, include the alexandrite, the 1064 Nd:YAG, and the Ruby. Extra-short pulses of these lasers give off bursts of energy that are absorbed by brown pigments. Tattoos usually require at least two different lasers that target different dyes.

The pulsed-dye laser (shown at left) is used to treat red spots, dilated blood vessels, spider veins, and broken capillaries. This laser emits a yellow light, which targets reddish pigments in the skin. The Q-switched laser (shown at right) gives off bursts of energy that are absorbed by brown pigments in the skin. As a result, this laser is used to eliminate liver spots, freckles, and some tattoos.

Longer pulses of the same wavelength used to treat pigmented lesions destroy larger targets and are used in removing unwanted dark hair. To date, no laser effectively removes light or gray hairs, which lack dark pigments.

The length of time for treatment and recovery varies depending on the laser, the size of the treated area, and the extent of the problem. Your doctor can provide you with detailed information about how the procedure will be done and what you will need to do during the recovery period.

Last updated:	July 20, 2007