Lasers and Light-based Devices
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IAPAM Demystifies Cosmetic Laser Treatments
The IAPAM’s Aesthetic Medicine Symposiums represent the most comprehensive, minimally invasive modality, and laser treatment training for physicians new to the aesthetic medicine field. The IAPAM’s multi-day Aesthetic Medicine Symposium program focuses on the top 5 minimally-invasive treatments: botox, dermal fillers, medical microdermabrasion, chemical peels, laser treatments and light procedures.
The IAPAM focuses on training physicians and their medical staff in the best practices for device-based aesthetic medicine treatments using laser treatments, light sources and radiofrequency devices. Part of the IAPAM training is to educate physicians on both best practices and possible complications, including:
78% of complications occurred in non-traditional medical facilities, such as freestanding medical spas and laser centers in shopping malls;
46% of complications occurred with hair reduction;
21% of complications occurred with Laser/Light leg vein treatments; and
42% of complications were permanent.
Part of the IAPAM’s training includes overviews of current clinical research. In a recent study by Vic A. Narurkar, M.D et al, it was reported that, “eighty two percent of all complications [with device-based procedures using lasers etc.] occurred in facilities that had no direct physician supervision. Of these, 57% were in facilities with a “medical director” who had limited training in dermatologic procedures and laser/light-based therapy. Of all the complications, 78% occurred in non-traditional medical facilities, such as free-standing medical spas and laser centers in shopping malls.
Lasers fall into two categories; ablative and non-ablative. A laser works by vaporizing the top layer of the skin to remove blemishes, scars and wrinkles.
Lasers that remove the top layer of the skin are called ablative lasers and include erbium and CO2 lasers.
Lasers that are capable of removing tissue beneath the first layer of skin (in the epidermis) are called non-ablative lasers. Non-ablative lasers are also called “wounding lasers” as they cause a more extensive and deeper “controlled injury” to the skin.
All lasers work by producing a single wavelength (color) of light. In essence the laser produces a controlled injury to the skin that causes just the right amount of damage to promote new cell growth.
The ablative laser affects only top layers of the skin and allows for healing of superficial problems due to photo aging (sun damage) or chronological aging.
The non-ablative laser removes skin damage that is much more severe and the recovery time with a non-ablative laser is much swifter than it is when conventional ablative lasers (such as the CO2 and erbium type) are used. It is a sophisticated laser skin rejuvenation procedure.
Figures from the American Society for Aesthetic Plastic Surgery (A.S.A.P.S.) indicate that laser skin resurfacing was the sixth most common cosmetic treatment in the U.S.A. in 2009 with over 512,000 treatments, a decrease of 10.3% on 2008 statistics. The number of treatments quoted by ASAPS included 27.2% carried out with an ablative laser and 72.8% with a non-ablative laser.
Non-Ablative Lasers for Skin Resurfacing
Non-ablative lasers are the newer technology. Instead removing the top layer skin tissue, non-ablative lasers work beneath the surface skin layer to improve skin tone and texture and get rid of wrinkles. During the procedure, a computer is used to control different colors of laser light to correct all kinds of different problems.
In non ablative laser skin resurfacing:
A yellow pulsed light is used to correct such conditions as red or wine colored birthmarks, enlarged blood vessels, scars from acne rosacea or any reddened area of the face (such as a red nose caused by alcoholism.) It can also be used to treat stretch marks.
A green colored ablative laser light is used to correct scars and marks that have a brownish hue to them such as freckles and age spots.
A ruby red laser is used for tattoo removal, age spots, freckles and for general facial rejuvenation.
Applications of Non Ablative Laser Treatments
The applications of the three types of non-ablative laser skin treatments are effective at:
- Eliminating fine lines on the upper lip, cheeks, and forehead
- Smoothing and tightening upper and lower eyelid skin
- Removing crow’s feet around the eyes
- Softening frown lines
- Removing freckles and brown spots
- Removing age spots
- Removing tattoos
- Removing stretch marks
- Removing burst blood vessels
- Reducing redness in the skin
- Flattening scars
- Repairing smoker’s lines
- Smoothing and polishing the complexion in general for a more youthful appearance
The Benefits of Non Ablative Lasers
The benefits of non ablative laser skin surgery are reduced healing time, less risk of infection and less time spent in the doctor’s office. The procedure is done on an outpatient basis and can take anywhere from two minutes to two hours to complete.
If you are light skinned then non ablative laser skincare will work for you. If you have dark skin then ablative erbium laser resurfacing might be preferable as it is less likely to cause hypopigmentation (lightening of the skin).
Another use of the non-ablative laser is for long lasting permanent hair removal. This is because the laser is able to reach below the first layer of skin and kill the root of the hair in the hair follicle. The only drawback of non-ablative hair removal is that it does not work with light hair on light skin and it cause depigmentation in dark skin. It works best on people who have dark hair on white skin.
Non Ablative Recommendations
As the non-ablative technology is newer technology it is not always offered by all plastic surgeons. If your plastic surgeon does not offer non-ablative laser treatments it may be simply because he does not own the equipment or have the training. Laser and skin surgery centers are numerous, so it is recommended that you consult with the American Society of Plastic Surgeons in order to find a plastic surgeon that is trained in non-ablative laser surgery that is located nearest you.
Ablative Lasers for Skin Resurfacing
Ablative lasers briefly direct an intense burst of laser energy onto the surface of the skin. This energy heats water within the surface layers of the skin, causing both the water and the tissue of the skin to turn to vapour. Every time the laser passes over the skin, some of the outermost layers of the skin are removed in a precise and controlled way to the appropriate depth:
The skin then heals over a period of time, as new layers of collagen are produced. The skin can literally resurface itself, causing an improvement in the appearance of sun damaged or acne scarred skin. After the treatment, the skin will look much healthier than it did previously. This intensive treatment can significantly reduce the appearance of lines, wrinkles, and pigment (or skin colour) changes on the face, neck, and other parts of the body. They can be used in sensitive areas, such as lines around the lips, eyes and even eyelids, or over the whole of the face. Acne and other types of scars and certain stretch marks can also be improved.
There are two main types of ablative laser – the original machines used were carbon dioxide lasers, and more recently erbium:YAG laser systems have been introduced.
Patients should expect laser skin resurfacing to cost between $2000 to $3000 US. According to the American Society of Plastic Surgeons, the national average cost for laser skin resurfacing is $2,378.
Laser Skin Resurfacing Price Breakdown
The cost of laser skin resurfacing will involve several factors. The laser skin resurfacing cost that is initially quoted tends to be the surgeon’s fee, but the patient will likely have to pay facility costs as well. The procedure may be performed in a surgeon’s office, an outpatient surgical facility, or a hospital. Hospitals are the most expensive places to undergo the laser skin resurfacing procedure, but they are also the safest and may be the best choice if you are undergoing another surgical procedure in conjunction with the laser procedure or are undergoing a particularly extensive or complicated treatment. The surgeon’s fee itself will be larger if you are undergoing a complicated procedure or treating a larger area of the skin.
During the procedure you will need to be placed under either local or general anesthesia and that will be part of the total laser skin resurfacing price. General anesthesia can be expensive, but many people wish to save themselves discomfort and anxiety by sleeping through the procedure. Patients should also factor pre- and post-operative care costs into their economic calculations, as well as the expense of post-treatment pain medication. Swelling and tenderness are commonly experienced side effects during the laser skin resurfacing recovery period. Another revenue stream for physicians may be special makeup to camouflage the redness of the treated area that may persist for several months following treatment.
There are 4 main categories of lasers used in dermatology:
- Gas Lasers: Carbon dioxide, Argon, Copper vapor etc. These are the first lasers which emit a constant beam of light for longer durations of exposure.
- Solid State Lasers: Ruby, Nd:YAG, Er:YAG, KTP, Alexandrite etc. These emit interrupted emissions of constant laser energy.
- Liquid Lasers: Dye lasers. Pulsed dye lasers emit high energy laser lights with very short pulse durations and longer intervals between each pulse.
- Diode Lasers: Diode lasers have several wavelengths and are suitable for soft tissue procedures.
- CO2 Lasers: The laser light from these lasers are absorbed by water in the skin, hence, used for skin resurfacing, removal of benign skin tumors like warts, xanthelasma, mucous cysts, cherry angiomas, leukoplakia and for surgical cutting.
- Nd:YAG Lasers: The active medium is Neodymium in yttrium-aluminum-garnet and the wavelength is 1064 nm. NdYAG lasers have slight absorption in melanin and hemoglobin and are used for laser hair removal, laser vein treatments, laser photo rejuvenation, laser acne treatments and in laser skin surgeries.
- Q Switched NdYAG Lasers have strong absorption in dark tattoo inks, hence used in laser tattoo removal.
- Er: YAG Lasers have a wavelength of 2940nm and the active medium is Erbium in yttrium-aluminum-garnet. It is absorbed by water in the skin and is used for skin resurfacing, laser photo-rejuvenation and for removal of skin growths.
- Ruby lasers have a wavelength of 694 nm and contain Chromium ions in aluminum oxide as the medium. Ruby laser light has very strong absorption in melanin and black and dark blue ink pigments. These are especially useful in tattoo removal. Laser hair removal and removal of pigmented (dark) skin lesions.
- KTP or Potassium Titanyl Phosphate Laser with 532 nm wavelength is a frequency doubled NdYAG laser with absorption by hemoglobin and melanin and used to remove vascular and pigmented skin lesions.
- Alexandrite Lasers: 755 nm, Q switched mode laser, used to remove blue, black and green tattoos and epidermal and dermal pigmentations as in melasma.
Fractional Lasers are the latest lasers which produce microscopic treatment zones and target specific depths in the dermis. These are especially useful for the treatment of acne scars, wrinkles, sun damaged skin, melasma etc. Wavelength is in the range of 1550 nm, and the target chromophore is water within the tissue.
- Diode Lasers: With different wavelengths. The absorbing chromophores are melanin and hemoglobin in the skin. Diode lasers are used for laser hair removal, dilated vein treatments, and laser photo-rejuvenation.
- Dye Lasers contain organic compounds in solution (often rhodamine) as the active medium and have wavelength activity between 400 to 800 nm. The target chromophores are hemoglobin and melanin pigment. Dye lasers are useful in treating vascular lesions and for non-ablative skin rejuvenation.
- Excimer Laser containing compounds of xenon, krypton and argon target proteins and water and have wavelengths between 190-350 nm. Excimer lasers are useful in the treatment of psoriasis and vitiligo.
Overview of the Use of Lasers for Hair Removal
Temporary hair removal is accomplished with conventional treatments such as shaving, waxing and epilation. Another method is the use of selective photolysis, which is light energy that is produced by the laser, and is targeted at the pigment in hair. This causes destruction of hair follicles while sparing surrounding structures (i.e., the skin).
Long lasting hair removal can be achieved with the use of several available lasers. Total temporary hair removal, which lasts for several months, can be done in almost all patients. However, total permanent laser hair removal is not commonly done. Stable permanent hair removal may be possible in some cases and usually requires multiple treatment sessions.
It is important to note that the FDA and medical associations make a clear distinction between permanent and complete hair loss or removal. Complete hair loss refers to a lack of regrowing hairs (ie, a significant reduction in the number of regrowing hairs to zero). Complete hair loss may be either temporary or permanent. Laser treatment usually produces complete but temporary hair loss for 1-3 months, followed by partial but permanent hair loss. Histological observations show damage predominantly in hair follicles with large, pigmented shafts, while hair follicles with small (<25 mm), hypopigmented shafts do not demonstrate any morphological change.
Lasers Used in Hair Removal
Ruby Laser (694 nm, normal mode)
- All patients will see a growth delay of their hair. Some patients will see a permanent reduction in hair growth.
- This laser is more effective for dark hair. Blonde and gray hairs are more resistant.
- White hairs do not respond to treatment
- Epilaser® (Palomar) and Epitouch® (Sharplan) are examples of ruby lasers
Alexandrite Laser (755 nm, normal mode)
- All patients will see a growth delay of their hair. Some will see a permanent reduction in hair growth.
- It is effective for dark hair. Blonde and gray hairs are more resistant.
- White hairs do not respond to treatment
- It is potentially safer for darker skin than the ruby laser
- Rapid repetition rates of the laser will reduce treatment time
- Apogee® (Cynosure) uses a cooling gel on the skin
- Gentlase® (Candela) uses dynamic cooling spray
Pulsed Diode Laser (800nm)
- Patients with thick or coarse hair will see a delay in hair growth. Some patients will see a permanent reduction in hair growth.
- It is effective for dark hair. It is not effective for fine hair.
- Potentially, it is safer for darker skin types
- LightSheer® (Coherent) uses contact cooling
Intense Pulsed Light Source (500-1200 nm)
- It is effective for dark hair, both fine and coarse
- It is potentially useful for darker skin types
- Epilight® (ESC) uses cooling gel
Nd:YAG Laser (1064 nm, Q-switched)
- Permanent hair removal has not been demonstrated
- It can temporarily remove light hairs
- It is potentially safe for all skin types, and causes the least epidermal damage of all treatments.
- Carbon suspension is applied to skin in some treatments
- There is a lower risk of epidermal damage
- Short operative times are required
- It causes the least discomfort of all laser hair removal treatments
The typical cost of laser hair removal is $150 to $500, depending on the area of the body that is being treated. In most cases, the smaller the surface area to be treated, the lower the treatment cost.
According to the American Society of Plastic Surgeons, the average price of laser treatments in the United States is $429.
The cost of laser hair removal in the smaller, bikini area is between $350 and $500.
The cost of treating a larger area, such as the back, averages between $600 and $900 per treatment session.
However, treatment of the chest will only cost between $350 and $600.
For the upper and lower legs, patients can expect to pay from $600 to $850.
The arms, on average, will cost only $350 to $500.
The underarms are the cheapest area to treat, with a cost range of $250 to $350.
Removing hair on the face and neck is comparable to the cost of laser hair removal on the back, with prices averaging $600 to $900 per treatment.
Other Uses of Lasers: Hair Growth, etc.
Ironically, one of the newest applications for lasers in aesthetic medicine is in hair regrowth. Low level laser therapy (LLLT) also known as laser biostimulation, photobiomodulation and cold laser therapy is now used for the treatment of hair regrowth.
It is believed that LLLT may increase blood flow to a treated area as well. European studies have shown that LLLT stops hair loss in 85% of cases and stimulates new hair growth in 55% of cases. In January of 2007 a hand-held laser therapy device was cleared by the FDA as a treatment for ‘androgenetic alopecia’ (male pattern hair loss). Low Level Lasers have been approved in this country as a treatment for carpal tunnel syndrome, as a wound-healing aide, and as an adjunct to liposuction procedures. Laser therapy has been safely used for decades throughout Europe, the Far East and has no documented side effects.