The Laser Pendulum Swings

It’s not that people are happy about enduring the recovery associated with full-field facial laser resurfacing; rather it’s that some patients are realizing that the downtime comes with dramatic results that simply aren’t possible with less aggressive lasers, according to Joel L. Cohen, M.D., director of AboutSkin Dermatology and DermSurgery in Denver, Colo.

Even a series of fractional ablative lasers aren’t going to make much of a dent in severely photodamaged skin of patients with deeply etched lines around the mouth, eyes and even cheeks. And in some practices, patients are beginning to buy in to the reality that when it comes to treating deeply etched lines on the face, full-field erbium 2940 is the right tool for the job, according to Dr. Cohen.

Dr. Cohen, who uses Sciton’s Contour, a full-field ablative erbium resurfacing 2940 nm laser for heavy facial resurfacing, says erbium 2940 nm full-field laser devices are safer and more versatile than CO2 full-field lasers of the past. He will often treat a patient’s deeply etched facial lines with heavy full-field erbium resurfacing, and then use fractional ablative resurfacing — either erbium or CO2 — for the rest of the face.

“I’m still using the ablative fractional devices every day for facial resurfacing and for scars, but we need to realize that different areas of the face have different degrees of photodamage, etched lines and elastosis,” he says. “If you take somebody’s cheek and compare it to the upper lip, or someone’s forehead and compare it to the upper lip, these regions look very different. The etching is much more significant for most people on the upper lip, so it makes sense to use different settings and different types of modalities and in some cases a combination of modalities — both full-field ablative and fractional ablative in combination to the same area — to do this.”

Patients are more willing to listen to the concept of doing something with more significant downtime once, maybe twice, when Dr. Cohen explains that the alternative is taking the day off multiple times for smaller procedures, like fractional ablative lasers, which cumulatively may amount to about the same actual aggregated number of days in recovery time, according to Dr. Cohen.

“I think the key is showing them my own patient photos of one to two full-field erbium 2940 laser sessions with the associated photos of downtime, compared to a series of even higher density just fractional laser resurfacing sequences,” he says.

Like other aesthetic medicine experts, Rebecca Kazin, M.D., associate director, Washington Institute of Dermatologic Laser Surgery, Chevy Chase, Md., realizes that results from noninvasive treatments don’t often equal those of more aggressive laser treatments. But she says it remains a challenge to recommend more aggressive treatments where she practices.

“Where I practice, patients are extremely conservative about having a treatment that has a prolonged healing time. They do not want to take off work and are very concerned about looking overdone. They prefer having multiple lighter treatments versus one heavier treatment, even when they understand that they may be compromising somewhat on the results,” she says.

Dr. Kazin, who uses a fractionated CO2 laser, says that she also often uses a combination approach, focally treating deeper lines with the more aggressive treatment to lessen overall healing time.

“I’ll do an ablative treatment to a focal problem area like the upper lip, and then do a lighter ablative or a non-ablative treatment for the rest of the face. This is a useful strategy that seems to satisfy a lot of patients,” she says.

Dr. Kazin will also combine focal fractionated CO2 laser treatment with a non-laser modality.

“Most recently, I have been applying carbolic acid directly into the deepest etch lines of the upper lip then lasered over the entire treatment area,” she says. “I have also combined the fractionated ablative laser with post laser application of a collagen stimulator like hyper-dilute poly-L-lactic acid (Sculptra, Galderma). I have found this to have a synergistic effect for stubborn etched lines.”

The Pendulum Swings

The pendulum has by no means swung away from less aggressive lasers, which remain an important part of facial rejuvenation.

Dr. Kazin says lasers have revolutionized her practice, and she agrees that they’ve gotten safer and more powerful.

“When advising patients on treatment options, I first determine what concerns they have and what is the most safe and effective treatment. Many times, for issues like redness, brown spots, wrinkles, pores and acne scarring, a laser can be used to at least partially if not fully address their concerns,” Dr. Kazin says.

NEXT: Lasers Offer Improved Safety, Shorter Recovery