Photo Rejuvenation for Better-Looking Skin: What Doctors Are Saying

Roundtable discussions appearing in Consumer Guide to Plastic Surgery are derived from comments from leading plastic and cosmetic surgeons who are recognized experts in their fields. Biographies of the doctors who participated in this roundtable discussion are at the end of the article.

Photo rejuvenation involves using an energy-delivery device to improve skin texture, fine wrinkles, scars, and hyperpigmentation (skin discoloration such as sun spots, age spots, and freckles). Photo rejuvenation falls into three categories: mechanical, thermal, and chemical. Mechanical methods include lasers, thermal include Thermage, and chemical includes chemical peels.

Specificity is the key word when it comes to energy-delivery devices. Lasers, for example, are energy-delivery devices with very specific applications. There are many different types of laser, each of which has unique characteristics (wavelength, power, and length of pulse duration) tailored to a particular kind of skin problem. Each type of laser uses a specific wavelength of energy applied to a specific area of the skin for a select type and severity of imperfection. Thus, more than one laser may be necessary to achieve maximum benefit, especially in skin with multiple areas of concern.

More recent is the advent of a light therapy device said to achieve benefits equivalent to a three-millimeter brow-lift, without the invasive surgery of a traditional brow-lift.

Photo rejuvenation technology is always changing and improving. We've asked the doctors in this roundtable discussion to explore some of the most common uses for these new technological advances.

Why did your patients choose photo rejuvenation?

Photo rejuvenation is not meant to be a substitute for surgery or other semi-invasive treatments such as chemical peels. However, photo rejuvenation is useful as an added tool for problems that cannot be otherwise treated, or to improve the results of other treatment options. One of the main attractions of photo rejuvenation is the fact that these treatments cause little or no downtime and few side effects for patients.

What are some of the patient expectations that you set in your office?

Knowledgeable patients must have reasonable expectations about the procedure. They should understand that multiple treatments may be necessary in order to achieve the desired result. They must also understand that results for specific conditions such as wrinkling may be incremental, just as sun damage results may vary, depending on the aftercare skin regimen. At the same time, photo rejuvenation has been the best approach for other conditions such as vascular lesions.

Patients receive a list of preoperative and postoperative instructions that should be followed to reduce the risk of complications. For example, an occlusive (airtight and watertight) dressing and ointment application may be required after the procedure. An alternative to a tape dressing is the LaserSeal, a transparent, occlusive silicone dressing, which is designed to offer long-lasting comfort and is delivered through a dispensing gun following laser skin resurfacing treatment.

Before treatment, the doctor explains any risks associated with the procedure. When performed by a properly trained physician for the correct indication, these treatments are safe and effective, offering improvements over traditional skin care or enhancing other procedures.

What are the most common medical conditions that you would treat with energy-delivery devices?

Skin Disorders

• Acne: Numerous effective types of treatment exist for acne. Lasers, including CoolTouch and Smoothbeam lasers, have been used for acne management, as have other heat-based (thermal) or light-based modalities. Photodynamic therapy with the blue light, intense pulse light, and/or the pulse dye laser system may be useful for mild acne. These are often used in addition to topical and/or oral medications already prescribed by the patient's physician.
• Acne Scars: Few non-invasive treatment options exist for the treatment of acne scars, and often the improvements are minimal. Previously, acne scarring was treated with dermabrasion or chemical peeling, with varying results. However, acne scars can be most effectively treated through laser resurfacing.
  
  Older CO2 lasers or second-generation erbium/YAG lasers were effective, but produced side effects. The more recent third-generation erbium/YAG-CO2 combination laser has been very effective for acne scars, without the side effects of older laser types. Recently introduced for this treatment is the very effective Fraxel laser, so named because it was designed to treat a fraction of the skin at a time, in thousands of tiny but deep treatment zones, but leaves surrounding skin untouched.
• Rosacea: Some practices use an intense pulsed light (IPL) energy device for the treatment of rosacea, while others use the pulsed dye laser, both with good results, but with different side effects (such as possible bruising with the pulsed dye laser).

Visible Vascular Lesions

• Matted Telangiectasia: These lace-like webs of tiny, dilated, red, blue, or purple capillaries, arterioles, or venules are visible just below the skin surface. The pulsed dye laser and intense pulse light have proven useful for matted telangiectasia or other small, annoying blood vessels. Localized telangiectasia and isolated vessels can be treated with the frequency-doubled Q-switched Nd:YAG (KPT) laser. Larger areas of telangiectasia can be treated with the pulsed dye laser or longer-pulse V-beam dye laser.
• Lentigines: Lentigos are dark areas of skin discoloration and are similar to age spots or sun spots. Some forms of lentigo may also be considered premalignant. Lentigines have been treated with the frequency-doubled Nd:YAG (KTP) laser, Q-switched Nd:YAG laser, Q-switched ruby, intense pulse light, or alexandrite laser.
• Cherry Angioma and Spider Angioma: Cherry angiomas and spider angiomas have a core group of blood or lymphatic vessels with dilated surface vessels or blebs (like tiny blood blisters). Cherry angiomas and spider angiomas have been treated with the KTP or pulsed dye laser.
• Vascular Lesions: The flashlamp-pumped dye laser (pulsed dye laser) has been used to treat vascular lesions with small-diameter blood vessels close to the surface of the skin, such as vascular birthmarks (see port wine stain below).
• Blue, Red, or Purple Port Wine Stains: Port wine stains are vascular birthmarks that do not go away without treatment. They respond well to the flashlamp-pumped dye laser (pulsed dye laser) or longer-pulse duration dye lasers (V-beam and others).
• Red or Blue Facial and Leg Veins: Injection sclerotherapy, which is the injection of a solution into a vein to force it to close up and become scar tissue that fades from view, has been the procedure of choice for treatment of spider veins that are large enough to get a tiny needle into. Now pulse dye or KTP lasers and intense pulsed light (IPL) therapy can successfully reduce the appearance of many unsightly blood vessels without needles, and with few side effects or risk of scarring.

Birthmark and Tattoo Removal

• Tattoos: Most professional or self-applied tattoos, regardless of color, can be successfully removed with Q-switched, ruby, alexandrite, or Nd:YAG lasers. Blue or green colors may respond somewhat better to the (Q-switched) alexandrite laser. In all cases, multiple treatments are necessary at no more frequent than four-week intervals (to allow proper healing between treatments). Some patients may experience skin color lightening, mild scarring, or incomplete tattoo ink removal.
• Vascular Birthmarks: Pulsed dye laser and/or intense pulse light treatments have been effective for improving the appearance of vascular birthmarks (such as port wine stains, mentioned above). Multiple treatments are needed for maximum lightening, at two-month intervals.

Hair Removal

• Nd:YAG laser treatments have been an effective option for permanent hair reduction for dark skin, and other laser wavelengths and IPL treatments are also used with good results. For example, the 810nm diode laser and alexandrite laser are excellent options for all skin types, except dark skin. Multiple treatments are necessary for maximum long-term hair removal. Hair removal treatments in 2004 totaled more than 900,000 sessions, indicative of the popularity of this treatment, and the reason so many laser hair removal med spas are appearing on the landscape.

Sun Damage and Aging Skin

• Photo-Aging, Hyperpigmentation, and Large Pores: Intense pulsed light (IPL) systems have proven useful for sun damage, hyperpigmentation, and large pores. The Fraxel laser has also proven useful for the improvement of brown spots, age spots, and large pores.
• Skin Irregularities, Fine Lines, and Dark Skin Discoloration: CO2, erbium/YAG, and combination CO2-erbium/YAG lasers have been beneficial for skin irregularities, wrinkles, acne scars, and certain types of skin discoloration. The Fraxel laser has also been effective for improvement of acne scars and fine lines.
• Sun Damage: Pulsed dye lasers or IPL are used for sun damage and aging skin. However, the length and level of lasting results varies among patients.
• Pigmented Lesions: A combination of a frequency-doubled Q-switched Nd:YAG (KTP) laser and possibly an IPL is useful for pigmented lesions. In some cases, topical therapy is part of the treatment plan. Laser treatment is not recommended for removal of dark moles.
• Melasma: Kligman's formula (an ointment containing hydroquinone, tretinoin, and dexamethasone) followed by frequency-doubled Q-switched Nd:YAG (KTP) laser or IPL has been effective for the management of melasma, a patchy or generalized dark or tan discoloration of the skin. The Fraxel laser is a potential treatment for melasma, as well.
• Post-Traumatic Hyperpigmentation: Post-traumatic hyperpigmentation sometimes responds well to the frequency-doubled Q-switched Nd:YAG (KTP), alexandrite, or ruby laser and IPL.
• Wrinkles and Sagging Skin: Aging of the skin includes one or more elements — such as droopiness of the tissues, loss of volume, and loss of elasticity — causing wrinkling and surface discoloration. Other than ablative (removal) treatments (such as dermabrasion, chemical peel and laser resurfacing), non-ablative treatments are many, with multiple approaches, such as infrared light, low-level laser, IPL, and even radio-frequency devices.
  
  The results for wrinkles and sagging skin from these photo rejuvenation treatments are still under investigation, as the technology continues to evolve and the number of doctors with extensive expertise in this particular area is limited. At the same time, certain energy-delivery devices may assist with a specific element. One of the latest radio frequency devices may lift a brow two or three millimeters and delay the necessity for brow-lift surgery. But the longer-lasting and effective repair of sagging skin without surgery is difficult to achieve thus far. The best and most effective fine surface wrinkle treatment uses the erbium/YAG and/or CO2 combination laser, but this requires an anesthetic and a week of shut-in time for healing.
  
  There have been reports that IPL therapy does help in collagen and elastic fiber production. Collagen supports fibroblasts, which act as bridges of support for the skin just below the skin surface. Collagen production decreases with age, so the stimulation of collagen production through light therapy or lasers can help reduce the effects of aging on the skin.
• Thermage: Another type of energy-based device is Thermage, recently FDA-approved for improving the appearance of sagging facial skin, smoothing wrinkles, and improving facial contours.
• Scars: Keloid and hypertrophic scars (scars that are abnormally enlarged) can respond to 585-nm pulsed dye laser (PDL) treatments. Raised scar edges may require an additional laser such as the Er:YAG or CO2 laser system. Surgical scars have been improved with the use of resurfacing lasers. However, the results for surgical scar reduction are not comparable to results for other types of smaller or more superficial scars. As mentioned above, the Fraxel laser is also very effective at improving acne scars.

Does the level of expertise in photo rejuvenation vary among doctors?

Yes, some practices do not perform photo rejuvenation. Others may perform photo rejuvenation for specific conditions and not others. Since the technology is fairly recent and continues to evolve, the level of expertise varies among doctors, as does the availability of different technology. Patients are advised to ask their doctor how many times he or she has performed the procedure, how often patients have had side effects, how many treatments are estimated for their particular case, and how long the treatment is expected to last.

The use of a laser requires proper training and extensive expertise. Doctors are typically trained to use a specific laser by the manufacturer of the equipment. Certification may require attendance at a training course, but this provides the physician with limited or no hands-on experience. Hospital credentialing occurs when doctors have obtained hospital privileges to perform these specific procedures, meaning that the doctor's training and experience to use the specific laser or energy-delivery device has been reviewed by a group of experienced peers. To a significant degree, outcomes depend on the experience and technique of the doctor. Certification does not guarantee a successful outcome, but the type of certification can better identify the specific education and training a doctor has to use the equipment.

Doctor Biographies

Mitchel P. Goldman, MD, is a leader in dermatology, as well as in cosmetic surgery focusing on phlebology (the branch of science dealing with veins), laser surgery, and liposuction. He is board-certified as a diplomate of the American Board of Dermatology, and he practices in La Jolla, Calif., where he maintains hospital staff privileges at Scripps Hospital and the VA Medical Center. Dr. Goldman is also a volunteer clinical professor of dermatology/medicine at the University of California, San Diego.

Alastair Carruthers, MA, BM, BCh, FRCP(LON), FRCPC, is a cosmetic dermasurgeon who operates his own clinical practice in Vancouver and is also a clinical professor of dermatology with the Faculty of Medicine at the University of British Columbia (UBC). Dr. Carruthers is the current president of the American Society for Dermatologic Surgery for 2006-2007.

Bahman Guyuron, MD, was recently appointed chief of the Division of Plastic and Reconstructive Surgery, University Hospitals, Case Western Reserve University. In the past he has served as director of the Section of Craniofacial Surgery at the Cleveland Clinic Foundation and chief of the Division of Plastic Surgery at the former Mt. Sinai Medical Center. Dr. Guyuron is certified by the American Board of Surgery and the American Board of Plastic Surgery.

Richard Tholen, MD, FACS, is president and senior partner/owner of Minneapolis Plastic Surgery, Ltd. and has been in private practice for 18 years. Dr. Tholen completed his general surgery residency and plastic surgery fellowship at the Mayo Clinic and is board-certified in both specialties. He served as co-director for laser education at Abbott Northwestern Hospital and was co-chairman for annual courses in cutaneous laser surgery taught at Abbott's Laser Center, Minimally Invasive Care Center and Center for Cosmetic Care.