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A Guide to Lasers – And What’s Right For Your Skin

February 24, 2016

LASERS

Q: Are there anti-wrinkle lasers, per se? Which are best for skin texture issues? Do you believe that lasers are the best approach for crepe-iness?

A: In general, lasers that remodel collagen and stimulate collagen production throughout the dermis of the skin improve the appearance of wrinkles, texture, and crepe-iness. This is because the first two relate to weakening or irregular conformations of the dermal collagen, while the latter is a result of thinning of the dermal collagen. Remodeled and new collagen normalizes this layer so that it is more organized, more even in distribution, and deeper depth.

There is a surprising misconception that lasers take off the top layers of skin, leaving it white, and/or shiny/thinned. This is not the case. I suspect this mistaken patient belief relates to older methods of rejuvenation like dermabrasion, deep chemical peels, and old fashioned lasers, all of which did remove surface layers of skin and carried a risk of removing all normal pigment cells called melanocytes. (Today, I still see patients in the office who were treated in the 80s, 90s, and early 2000s with these older methods, and some do have these unusual signs of treatment.)

Fortunately, rejuvenating layers today generally penetrate the surface skin, stimulating the collagen from within and below and triggering its production, rather that simply shearing off the surface. This is because resurfacing lasers today are fractional – meaning that the laser beam is delivered in a pixelated manner, touching the skin in tiny dots, separated by areas of untreated skin. This leaves behind healthy pigment producing cells (melanocytes) and other normal skin cells unaffected by the treatment that rapidly heal the skin and markedly diminish the risk of abnormal pigmentation.

The most commonly used lasers for these strategies are fractional resurfacing lasers. The most popular ones are those with limited downtime (generally from a few hors of pink and dryness to 4-5 days of pink and dryness). My currently used strategies include the non-ablative (non-wounding) Clear and Brilliant lasers and Fraxel Restore dual lasers. Not only do these lasers stimulate the collagen, they also allow for a surface exfoliation of the skin, which sheds abnormal browning and dullness to the skin. Consequently, the skin looks brighter.

The stronger lasers are ablative (meaning they superficially wound the skin), leaving the skin with redness and scabs for about a week, followed by 3-4 weeks of pink skin. The later 3-4 weeks can generally be masked by makeup, since the skin has healed. These stronger versions are usually reserved for more substantial signs of aging, uneven texture, deep wrinkling, or scars – often acne scars. My preferred ablative fractional laser is Fraxel Repair.

More good news about these therapies: I was part of a clinical trial published in 2012 that demonstrated the likelihood that these newer fractional laser treatments promote not just more beautiful skin, but healthier skin as well, by supporting the elimination of pre-cancerous skin changes known actinic keratoses. These precancers have the potential to turn into squamous cell carcinomas.

Q: Which are best for tightening and fighting sagging?

A: The sciences that allow cosmetic dermatologists to tighten (i.e. fight sagging) ski is one of the fastest growing areas in our field. It is important to understand not all technologies are lasers. Lasers are beams of light that are simply one wavelength. Other forms of energy can be used on the field of cosmetic dermatology, including radiofrequency and ultrasound. Radiofrequency was one of the first technologies to help tighten skin. A popular system is Thermage. With this science, we can safely deliver radiofrequency energy into the skin to produce a heat throughout the underlying collagen fibers. This can stimulate remodeling of existing collagen and the production of new collagen. The result is a tightening/firming to the skin. This used to be a painful treatment, but innovations in delivery make it very comfortable. These strategies include vibration in the handpiece that touches the skin as well as cooling methods to comfort the surface skin.

Ultrasound is one of the newer technologies used in skin tightening and lifting. One of the popular systems is Ulthera. It allows me to safely deliver sound waves under the skin that focus to points at a very specific depths. Think of the way a magnifying lens can take sunlight, focus that light onto a leaf, and leave a burn. With Ultherapy, ultrasound can pass right through the skin surface painlessly, but be focused to meet at a specific point at a specific depth under the skin. At this meeting point, the temperature goes up, stimulating collagen remodeling and collagen production. This procedure tends to be uncomfortable, but like the Thermage science, has become more comfortable with strategies that include lower energy delivery with more passes of the sound waves.

Finally, it’s important to realize that cosmetic injections of Botox and filler also allow me to lift skin. With Botox, I am able to strategically place it into muscles that have a downward pull. These muscles include those immediately below the forehead and above the eye. Ideal placement here give people a noticeable brow lift. (Don’t worry about spock eyebrows – these are prevented by delicate placement of Botox in the forehead!) Botox can also be used in the chin to lift the corners of the mouth. And it can be injected into the neck to allow a lift to the jowls and neck bands.

Filler injections also give the face a lift. In the hands of someone other than an expert doctor, filler results in a full face – which is not the goal of filler. True appreciation for the placement of filler allows contour and lift. Injections underneath facial muscles and in areas where the young face once had more significant, supportive bone and fat pads, give a natural-looking lift. No one will know you were treated, but the face is re-contoured and lifted to prevent the appearance of sagging skin and jowls.

While these techniques are very exciting and becoming more popular, I cannot say that we can achieve the lifting outcomes of surgery.  But it also doesn’t carry the risks, scars, or permanency of surgery. Also, I theorize that remodeling and production of new collagen in the skin will slow the rate at which your skin sags over time, since the architecture of the skin is newer and healthier with these treatments.

Please note some of what is described above is off-label by the FDA but used routinely.

Q: What’s best treatment for dark spots.

A: The best treatment for dark spots is, without question, laser treatment once the spots appear. Topical products are helpful, but most helpful in eliminating the development of brown spots. Consistent use of sunscreen and retinoids helps maintain even, bright tone, while hydroquinone specifically diminishes pigment in any area you are treating. It is reasonable to use a hydroquinone to select areas once you start to see an area of unevenness developing; I review exhaustively with my patients that if they elect to use hydroquinone, that they need to be careful with the application. If it goes outside of the area of extra pigment, there may be a whitening at the rim of the normal skin.

The best laser treatments for dark spots fall into two major categories: pigment specific lasers and fractional resurfacing lasers. Pigment specific lasers are spot treatment therapies. They are used on one spot at a time and work by selectively heating the extra pigment particles in the target area. The names of these lasers are variable, but most commonly include Ruby lasers, Yag lasers, and Alexandrite lasers. Typically, the treated areas on the face appear as tiny surface scabs for several days to a week. So planning the right time for these treatments is important, since you may have several days of looking treated, even with makeup,

The other category, namely fractional resurfacing lasers, primarily build collagen in the skin, but also exfoliate the surface. There are many intensities of these lasers, from ones that leave the skin pink and dry for a few hours, to one that leaves it looking superficially wounded for a week and pink for another 3-4 weeks. The stronger lasers are usually used only for patients with dramatically spotty or wrinkled skin; most patients do great with options that leave them pink and dry for a few hours and pink and dry for a few days.

The best overall here is combination therapy. To achieve the optimal outcomes, I encourage all of my patients to protect their skin daily with sunscreen – even in winter and rainy days – and if their skin can tolerate it, retinol or prescription retinoids on a nightly basis. I say if they can tolerate it because the use of retinoids can make the skin irritated, but usually the skin becomes used to it, especially if the patient is moisturizing well. I use it nightly without any trouble. I then bring in the use of Ruby, Yag, and Alexandrite lasers for concentrated sun spots and fractional resurfacing lasers to diffusely exfoliate and brighten skin tone.

Q: What are the best to treat acne?

A: We can use blue and red lights to assist with anti-inflammatory processes of acne. But what I find more effective is integrating light and vaccuuming benefits in a process called photopneumatic therapy.

To read the full article featured in GOOP : ‘A Q&A with Robert Anolik, M.D.’ click here: http://goop.com/a-guide-to-lasers-and-whats-right-for-your-skin/

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Doctor Olson is board certified and is fellowship trained as an oculofacial plastic surgeon.
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Jane Olson, MD
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