By Andrea Alstad

The use of lasers for cosmetic treatments has grown significantly in the last 20 years. The demand for non-invasive treatments to address skin issues places lasers at the forefront of aesthetic procedures. Developments in technology have brought us almost to the limits of wavelength possibilities in lasers. Recent trends focus on determining the optimal methods to use for specific treatments and the tweaking of devices to gain better performance and improved safety. Further, cosmetic treatments are evolving by using additional energy-based technologies to enhance lasers, including focused ultrasound and radiofrequency.

Dr. Robert A. Weiss of the MD Laser, Skin and Vein Institute in Hunt Valley, Maryland and president-elect of the American Society for Laser Medicine and Surgery, is actively involved in the research and development of non-invasive cosmetic treatments. He is the author of over 150 publications, multiple textbooks and is an invited speaker for hundreds of worldwide scientific presentations. Weiss shared his thoughts on developments in the field of lasers and other energy-based devices for cosmetic use.

Are we on the same wavelength? Sorting through the cosmetic laser options
“The list of manufacturers and devices sold for cosmetic use today probably numbers in the hundreds at this point, so to narrow it down, it is better to think about the application first, rather than the device,” says Weiss.

One of the most common treatment areas that a dermatology practice addresses is the effects of sun exposure and photoaging. A practice may start with an intense-pulsed laser (IPL) device, where multiple wavelengths are administered at the same time. The IPL is probably the least complex and least costly device so it is often the first device that a practice purchases. Sometimes termed a “photo facial” treatment, IPL may treat a number of issues like pigmentation, texture and broken blood vessels all at the same time. A larger practice, with multiple health care providers, is able to make use of multiple devices which have a narrower focus and select the best laser or device in each category to treat more complex or stubborn cases.

Lasers for improving skin texture and treating photoaging currently fall into one of two categories, ablative and non-ablative, which are typically now both fractional lasers, treating a fractional portion of the skin. Ablative lasers work by destroying portions of the skin and causing the adjacent and treated skin to form collagen and heal into smoother skin. These are effective in cases of severe sun damage and pigmentation. The trade-off is the longer recovery period and need for greater pain management. Non-ablative and fractional resurfacing lasers, on the other hand, do not damage as much skin, but work from deeper layers to stimulate new collagen. While not as painful and with less down time, the tradeoff comes in the need for more treatments to produce desired results.

In addition, a number of alternate energy- based devices are finding uses in the cosmetic field, including focused ultrasound and radio frequency. Like non-ablative lasers, these methods do not disrupt the top layer of skin, but work by creating thermal injury underneath the skin.

Skin rejuvenation
For photoaging and pigmentation, an emerging application is the use of Qswitched non-ablative lasers that fire in nanoseconds (also used for tattoo removal). The newest and most promising are the picoseconds domain lasers which fire in trillionths of a second. “This is the hot new area, trying to understand all the benefits and to harness the advantages of such a short pulse duration,” says Weiss. “There is also investigation into lens arrays to break up the beam into tinier beams, which creates more intensity in little spots. The picosecond laser just received clearance from the FDA for wrinkles and acne scars, which helps expand the range of treatments and justify the investment. “

Fractional infrared non-ablative lasers, the latest based on thulium lasers, have been working very well for textural improvement of the skin and for the pigment component of aging.

The FDA has also cleared these lasers for safety and efficacy on actinic keratosis, which are pre-cancerous cells. “We have the capability to treat the pigment and kill the pre-cancers before they turn into cancers,” said Weiss.

The standard for really severe sun-damaged skin and scarring is the more invasive ablative fractional CO2 laser. The treatment provides greater improvement of the damage, but has a trade-off because it produces more redness and requires more pain control and downtime.

A new approach is the combination of devices at the same treatment session, such as a combination of ablative and non-ablative fractional laser resurfacing or two wavelength levels of non-ablative at the same treatment to achieve a better patient experience with less pain.

For complete patient satisfaction, many of the device treatments are part of a total rejuvenation program, which typically includes hyaluronic acid and other fillers to lift the face and neuromodulators to help with dynamic wrinkles — those created by muscle movement. “Even with the best laser, those dynamic wrinkles will return, because the muscle movement is constantly reinforcing those lines,” said Weiss. “We try to explain to the patient that with the laser, you are undergoing demolition of the old collagen and then reconstruction of the new collagen, which takes several months. Using these injectables in combination with the device treatment will provide a more satisfying and immediate result during the laser remodeling process.”

Vascular
For blood vessels and vascular lesions such as port wine stains, the best choices would be the pulsed dye laser which targets hemoglobin or a KTP filtered ND Yag Laser,with shorter green and yellow wavelengths strongly absorbed by blood cells.

Skin tightening and noninvasive fat reduction methods
There are a number of non-laser approaches that work for both tightening areas of the skin such as the neck, and fat reduction. “This has become a hugely popular area. As people get into their 40s and beyond, there is a greater likelihood of accumulating excess fat. All forms of energy-based devices are being used and developed for non-invasive fat reduction,” says Weiss.

A significant development several years ago was cryolipolysis or freezing of the fat cells. More recently, focused ultrasound is being used to break up fat, by causing non-selective thermal injury underneath the skin, bypassing the surface. While the technology has been around for several years, it has become quite popular more recently. The FDA has cleared this for marketing for fat cell destruction in the U.S.

Radiofrequency emits heat energy and is being used for skin tightening, as well as heating up and destroying fat cells. A larger area, such as the abdomen or flank, can be treated in a shorter period of time.

These skin-bypassing technologies can be effective with a wide range of patients, including those with darker color skin that may experience discoloration with a laser.

More light-based technology for non-invasive fat reduction is on the horizon. Weiss says, “We will have all forms of energy to reduce fat. In another two or three more years, I would say that liposuction will be the treatment of last resort, if the patient does not respond to the non-invasive options. We have seen some really nice results. There is no downtime. A patient can come in, take a treatment, walk out and go back to work. There is no long recovery period. That is probably one of the most exciting developments in recent years.”

Reimbursement for cosmetic laser treatments
Cosmetic laser treatments are not generally covered by insurance. A general rule is that “If it is cosmetic, it is not reimbursable.”However, under certain circumstances, such as treatment of a port wine stain, laser procedures that commonly are considered cosmetic may be deemed medically necessary.

Scars due to a traumatic injury are treated with lasers, but at this point in time, there is no code for a laser treatment of a scar. Weiss pointed to the scenario of laser scar treatment as part of the Wounded Warrior Project. Military dermatologists provide treatment at no cost while the patient is in the military, but when the patient is no longer in the military, treatment by a civilian dermatologist may be considered cosmetic and not reimbursable by the insurance company.“We need to see that change, scars are medical problems and effective treatments by laser need to be viewed as medical, not cosmetic treatments,” Weiss said.

Safety
“We are making quantum leaps in determining the optimal methods to use and the tweaking of devices to gain better performance and improved safety,” says Weiss. An ASLMS expert group meets with the FDA each year to help answer the questions about what’s really happening in the community with devices that are FDA cleared. The FDA wants to know what side effects we are seeing from which devices and how public safety can be best protected. Fortunately, as technology advances, more safety features are being built into the devices. A recent invention and additional to IPL is a skin reflectance reader which will measure the pigmentation of the skin and recommends the proper settings to avoid burning based on actual skin pigmentation at the time of treatment.

The future remains bright
“We have evolved into all of these multiple non-invasive methods to treat vascular, to treat pigment, improve skin texture and reduce fat,” Weiss says. “And the evolution has gone on to include more forms of energy than just laser. With all of the choices available now, it has become more confusing to the public and to the physicians as well, to choose the proper device and treatment. That’s where the American Society for Laser Medicine and Surgery (ASLMS) serves a more important function than ever. Weiss pointed out that the ASLMS annual meeting provides interaction between M.D.s or other providers who are treating patients, alongside the PhDs who are developing the devices, alongside the manufacturers who are implementing the designs of the PhDs. “Frankly, I don’t know of any other conference where you can attend sessions devoted to each of technologies, such as fat reduction, new developments in vascular lasers, and developments in skin tightening,” says Weiss. “Hundreds of clinical studies are presented each year to highlight the latest advances and newest devices on the market. I personally never miss an annual ASLMS meeting, there is no other opportunity to acquire the information that I need to learn each year.”

About the author: Andrea Alstad is the marketing and communications coordinator for the ASLMS.

About the ASLMS: The American Society for Laser Medicine and Surgery, Inc. (ASLMS) is the world’s preeminent resource for laser research, safety, education, and clinical knowledge. Founded in 1980, ASLMS promotes excellence in patient care by advancing product engineering and clinical applications of lasers and other energy based technologies. Currently, ASLMS has over 3,600 members, including physicians and surgeons representing more than 51 specialties, physicists involved in product development, biomedical engineers, biologists, nurses, industry representatives and manufacturers.