By Diane Donofrio Angelucci, contributing writer, November 01, 2013
New advances in cosmetic laser technology are broadening clinicians’ options in treating a range of conditions, optimizing their efforts to deliver the results their patients desire.
This article shares some of the latest developments in this rapidly expanding field.
Reducing body fat
Noninvasive devices, which entered the market only a few years ago, transformed approaches to body contouring, which formerly relied exclusively on invasive treatments such as liposuction, said Mathew Avram, MD, JD, director of the Massachusetts General Hospital Dermatology Laser and Cosmetic Center at Harvard Medical School.
“Noninvasive treatments are not as effective as liposuction,” Dr. Avram said. “However, what I think is really interesting is, over the past three to four years, the data from the American Society for Dermatologic Surgery confirms that, for every single liposuction treatment that is performed, there are six noninvasive treatments that are being performed by dermatologists,” he said. “Increasingly, patients are choosing procedures that provide a clear, but more modest, clinical benefit over more invasive procedures. The two primary reasons are to avoid downtime from work and social activities as well as a desire to avoid a higher risk for adverse side effects. Typically, the non-invasive procedures are quite safe with minimal, if any, downtime.” [pagebreak]
One body-sculpting technology is the CoolSculpting system (Zeltiq), which uses cryolipolysis to selectively reduce fat by freezing fat cells. Fat reduction can be observed two to three months after treatment, Dr. Avram said. In a study involving 33 subjects, Shek and colleagues reported that noninvasive cryolipolysis was effective in reducing abdominal fat and love handles in Chinese patients in the February 2012 issue of Lasers in Surgery and Medicine, with the first treatment having a more dramatic impact than the second.
Several body-sculpting devices use low-level light therapy to reduce fat in the skin; however, Dr. Avram said, data regarding their efficacy are limited.
Ultrasound is another approach. An article by Jewell in the December 2010 issue of the Journal of Clinical Dermatology reported that the average reduction in waist circumference with high-intensity-focused ultrasound treatment was as great as 4.7 cm. Liposonix is one such fat-melting device approved by the U.S. Food and Drug Administration (FDA). It is very effective, melting an average of one inch of fat per treatment per area, according to Min-Wei Christine Lee, MD, dermatologic surgeon in Walnut Creek, Calif. “But 50 percent of patients are actually losing anywhere from two to three inches per treatment,” she said.
Once the fat cells are destroyed, the body processes and disposes of the liquified fat through the body’s normal biological pathways, she explained. “Once those fat cells are destroyed, they never come back,” Dr. Lee said. [pagebreak]
Another body-contouring device, truSculpt (Cutera), which uses radiofrequency technology, was also released this year. “The results [of the company’s research] have been showing, after two treatments, you can get a bit less than a centimeter of fat reduction,” Dr. Lee said.
The Cellulaze (Cynosure) is the world’s first laser approved by the FDA to treat cellulite with only one treatment, Dr. Lee said. “Everything up until this laser has been much less dramatic in terms of results and, also, not lasting.” In the March 2011 issue of Aesthetic Surgery Journal, Barry DiBernardo, MD, reported that, in a study of 10 women with a mean age of 47, the technology improved the appearance of cellulite for at least one year after a single treatment with a 1440-nm laser, with improvements in skin thickness and elasticity.
Dr. Lee explained that the minimally invasive laser targets fat bulges; severs the fibrous connective septae, releasing the skin that causes depressions; and heats up the skin from under the dermis, creating a thicker layer of collagen.
The fiberoptic SideLaze 3D (Cynosure) is a new addition to the Cellulaze. “We’re using it to contour the lower face, jaw line, and neck to give something like a closed face lift,” Dr. Lee said. She has also been using the laser to treat deep perioral rhytides (“smoker lines”). [pagebreak]
With the growing popularity of cosmetic tattoos, clinicians are only too aware of the challenges of removing them for patients with buyer’s remorse.
A new technology may make it easier to remove tattoos and benign pigmented lesions. The PicoSure picosecond 755-nm alexandrite laser (Cynosure), featuring ultra-short-pulse durations, was introduced recently.
“The PicoSure is using the same wavelengths that we have available, but it’s just delivering that energy in a shorter amount of time,” said Nazanin Saedi, MD, assistant professor and director of laser surgery and cosmetic dermatology at Thomas Jefferson University Hospitals in Philadelphia. “Currently, for tattoos we are using Q-switched lasers, and they release energy in nanoseconds, but with the PicoSure it releases the energy in picoseconds.” Saedi and her colleagues reported in the December 2012 issue of Archives of Dermatology that the laser was safe and effective in removing tattoo pigment, with 100 percent patient satisfaction among 12 patients who completed treatment and an average of 4.25 treatments required to achieve 75 percent clearance.
In describing the laser’s approach, Dr. Lee likened the tattoo’s carbon molecules to rocks. A Q-switched laser would break it into pebbles, whereas the picosecond laser would break it into dust, she explained. Rather than requiring approximately 10 treatments, as may be required with the Q-switched laser, the picosecond laser treats the same tattoo in two treatments, with less residual pigment, Dr. Lee said. “It is also able to treat blue and green, which are notoriously resistant to any laser. It can treat them in two to four treatments, without leaving a shadow,” she said. [pagebreak]
However, Dr. Avram urged caution. “It looks like a promising technology for more effective laser tattoo removal,” he said. “It’s very early in the experience of these devices, so further study is needed.” (For more discussion of tattoo removal strategies, see www.aad.org/dw/monthly/2012/april/rebellion-and-remorse.)
Clearing vascular and pigmented lesions
In treating vascular and pigmented lesions, the Excel V (Cutera), a potassium titanyl phosphate (KTP) and Nd:YAG laser, is the new gold standard, said Dr. Lee, who helped develop it. “The KTP and Nd:YAG laser can treat any kind of vascular or pigmented lesion, which makes it much more versatile than the older pulsed dye lasers,” she said. She explained that the yellow-wavelength 585-nm pulsed dye laser can treat telangiectasias but not pigment, but the 532-nm green-wavelength KTP laser treats both vascular and pigmented lesions. Reddy and colleagues reported on this technology in the January 2013 issue of the Journal of Drugs in Dermatology, concluding that a single treatment could effectively achieve up to 75 percent improvement in port wine stains in a study involving five patients. [pagebreak]
Although clinicians have been using lasers for more than 20 years to target unwanted blood vessels, some childhood vascular malformations are less amenable to treatment or require many treatments, so clinicians are also combining laser treatments with topical or oral medications to enhance the effects, said Tina S. Alster, MD, clinical professor of dermatology at Georgetown University Medical Center in Washington, D.C. “Additional studies need to be performed, but in terms of proliferative hemangiomas, which may continue to grow despite the use of lasers, newer adjunctive treatments like propranolol have fewer side effects than others (like corticosteroids) used in the past,” Dr. Alster said. Reddy and colleagues reported on the use of pulsed dye lasers and propranolol to treat infantile hemangiomas in the March 2013 issue of Dermatologic Surgery, finding that the addition of PDL led to better outcomes for patients with hemangiomas — faster healing and a greater likelihood of complete clearance — than treatment with propranolol by itself.
Resurfacing the skin
Lumenis recently introduced a new addition to its UltraPulse laser, called the SCAAR FX, for treating hypertrophic scars, Dr. Lee said. “So if you have a very thick scar, you can get better and deeper penetration through that scar by this new add-on.”
A number of nonablative lower-energy fractional lasers have been introduced, which attract patients who are not ready to have more intense procedures, Dr. Saedi explained. “The results are not as dramatic, but these devices do improve the skin texture, pigmentation, and the appearance of pores. There is minimal down time.” [pagebreak]
Furthermore, the newer fractionated lasers and devices are smaller, more compact, and more user-friendly and tend to be less expensive than older devices used for laser skin resurfacing, Dr. Alster said.
Exploring available options
Because there are so many lasers and devices, choosing a new one that will best serve a clinician and his or her patients can be difficult, Dr. Alster said. “It’s important to identify the types of lesions that you anticipate treating and then hone in on the technology for that particular indication,” she said.
“A lot of laser systems have comparable technology and clinical effects, so it’s a matter of finding out which, in your hands, feels more comfortable and is most cost efficient,” Dr. Alster said.
Dr. Avram emphasizes the importance of considering the quantity and strength of the data reported for each device, the number of treatments that have been performed with the device, and its safety record. Furthermore, he recommends asking colleagues about their experiences with the devices.
To make the best choices, clinicians also need to remain abreast of advances in technology. “I feel like there’s so much research being done and so many advances being made,” Dr. Saedi said. “I would encourage people to stay on top of that.”
Editor’s Note: Dr. Avram serves on the Scientific Advisory Board of Zeltiq Aesthetics and has also served as a paid consultant for the company. Dr. Lee is an investigator for Cutera and Iridex. Dr. Saedi is a research consultant for Palomar. Dr. Alster does not have financial interests related to this article.
What procedures are dermatologists using lasers for?
Dermatologists are making increasing use of lasers to treat a variety of conditions, addressing both medical and cosmetic issues. What are the top uses of lasers in the specialty?
According to a survey conducted by the American Society for Dermatologic Surgery, ASDS members performed 1.68 million laser and light procedures in 2012. Among these were procedures to address:
- Photo rejuvenation: 438,000
- Facial redness: 322,000
- Age spots: 265,000
- Photodynamictherapy for AKs, sun damage, acne, and rosacea: 205,000
- Acne scars: 93,000
- Tissue tightening: 92,000
- Surgical scars: 86,000
- Laser resurfacing: 82,000
- Tattoo removal: 63,000
- Birthmarks: 39,000
The survey, conducted in January 2013, interviewed 630 ASDS members and generalized their experience to the society’s 3,705 practicing members.