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Laser Technology: Beauty and the Beam

Lasers are having a dramatic impact on the way dermatologic medicine is practiced today, but there are a number of popular misconceptions about what lasers can, and cannot do. Below, dermatologist Dr. Arielle Kauvar of the NYU Medical Center, and Dr. David Leffell, dermatologist from the Yale University School of Medicine and author of Total Skin, help us separate laser fact from fiction.

What is a laser, and how is it used in dermatology?
DAVID J. LEFFELL, MD: A laser is a device that emits an intense band of light. In medicine, lasers are used because those intense bands of light can be specially tailored for a particular purpose. Lasers can, for example, vaporize wrinkles off the surface of the skin and stimulate new skin, and they can remove pigmented age spots or tattoos. So a certain kind of light is used in a certain procedure or even a kind of skin problem?
ARIELLE KAUVAR, MD: Yes. For skin, we treat several different things. We treat things that are made out of blood vessels, which are red, and we treat things that contain pigment, which are brown. Different types of light are absorbed or interact with either red or brown colors. Skin pigment is varying shades of brown, and blood vessels are red. So these are the two colors that the laser interacts with. The reason we can destroy topical problems on the skin without harming anything else is that the laser energy is only absorbed by those spots and nothing else. So we can actually remove something without touching the rest of the skin as you would if you burned something off or cut it out.

Do you think the public is oversold on the magic, the promise of laser?
DAVID J. LEFFELL, MD: Absolutely. I think for people like Dr. Kauvar and myself who have active laser practices, we spend a fair amount of time correcting misperceptions. When we take care of patients, we have to make sure their expectations are realistic. Otherwise, they are going to be unsatisfied. Complete treatment, if you can get one hundred percent treatment, takes time. People are used to going to McDonald's, ordering a meal quickly and getting it. They are not used to waiting, even though the problem they have may have taken thirty years to develop. They want instant gratification.

Is this an outpatient procedure?
DAVID J. LEFFELL, MD: Yes. Many of these procedures can be done very safely and, in fact, were developed to be done in the dermatologist's office. The patient will receive either local anesthetic, just like at the dentist's office, or if a larger area is done, some dermatologists will have sedation running intravenously to make the patient more comfortable.

How long does the procedure generally last?
DAVID J. LEFFELL, MD: It depends. If you're treating just the lines around the mouth, in my experience, it's a twenty to thirty minute procedure. If you do a full-face treatment, of course it takes proportionally longer.

How long does it take before the patient will begin to see the results of the treatment?
ARIELLE KAUVAR, MD: Depending on the exact type of laser used and how aggressive the treatment, they'll heal in between seven and ten days. At that point though, even though they are healed, they may be bright red. So there are at least two weeks during which there is a fair amount of redness.

Most people have some residual redness after a month, but they could certainly go to any social function and feel very comfortable. After resurfacing procedures, new collagen starts to develop in the skin. It really doesn't begin until about eight weeks after the procedure. So at the three month point, individuals look much better than they do at the one month point. They usually look better at six months than at three months. So there is actually a gradual improvement.

Is there a point at which it all begins to deteriorate and then you have to have the procedure again?
ARIELLE KAUVAR, MD: There are long-term studies now that show that a significant amount of the improvement stays for years. Certain areas of the face will have some recurrence of the lines, but not to the extent that existed before. I think in that sense it is very much like a facelift. A facelift will give you years of improvement, but as you age and your skin gets looser, then some of those changes are going to come back.

How are lasers used for age spots?
DAVID J. LEFFELL, MD: This is a laser or a group of lasers that emit light at a wavelength that's more or less complementary to brown, blue, and black. There are many different age spots and brown spots that we get on the face and on the backs of the hands. In addition, there are also spots that we choose to get, namely tattoos. Such spots can be treated by a laser that is specifically designed to destroy that range of pigment.

We can use lasers specifically for brown spots where we don't have to peel skin. The laser attacks the pigment within the skin, and you get a fine crust for about a week. Then the crust peels off and the brown spot is gone. So it's very common to treat people with brown spots, or age or sun spots on the hands, chest and face.

How do lasers work to remove tattoos?
DAVID J. LEFFELL, MD: Again, erasing the name of an ex-girlfriend isn't as easy as patients often hope. In fact, it's important to emphasize to people that the removal of tattoos takes time. To remove a tattoo, assuming it's the right color and the pigment is at the right depth, easily takes four to seven treatments. People can't embark on a course of treatment unless they understand that.

Is it painful?
DAVID J. LEFFELL, MD: It feels like grease splatter or the snap of a rubber band. There are topical anesthetic creams that can be applied to take the edge off of the pain.

What is a vascular lesion laser?
ARIELLE KAUVAR, MD: We have a whole array of lasers that actually heat up the blood inside a blood vessel so the blood vessel becomes inflamed and dies, and then the body breaks it down. We use these vascular lesion lasers to treat a wide variety of things. We treat little capillaries on the face, which many fair skinned individuals develop in early adulthood. We treat rosacea, which is an adult acne condition that's associated with redness. We use them to treat individuals who have flushing or diffuse reddening of the face, red nose or red neck. We use these lasers to treat red birthmarks, like port wine stains or hemangiomas.

Are lasers successful in the treatment of spider veins, or varicose veins in the legs?
DAVID J. LEFFELL, MD: There is no question that there have been dramatic improvements in the use of laser for broken vessels in legs or varicose veins. But the reality is that as long as we walk upright, and as long as there is gravity, there is a high risk of recurrence. I think that laser is only helpful up to a certain diameter vessel. It's not that the lasers don't work. It's that the anatomy is working against us.

How do hair removal laser treatments work?
DAVID J. LEFFELL, MD: They target the bulb of the hair follicle, which then absorbs energy, becomes damaged, and shrinks. These lasers don't yet completely eliminate hair, but they reduce the caliber of the hair that grows back, so it's much less noticeable.

How long does it take?
ARIELLE KAUVAR, MD: We can cover huge areas very quickly. So we can treat an entire back in twenty to forty minutes, depending on the laser system, whereas if one attempted to do that with electrolysis, it would take months or years.

Is laser treatment for hair removal suitable for everyone?
ARIELLE KAUVAR, MD: The lasers are actually running after the pigment in the hair itself. So these lasers that give you the long-term hair reduction actually are ineffective, for the most part, on white or blond hair.

For the same reason, if someone has very darkly pigmented skin and the laser is interacting with pigment, then that becomes more of an issue. However, in the last year they've developed variations on the technology they've been using. Ongoing studies now suggest that we can actually safely remove hair in the darker skin population as well. So I think in the next year or two we'll be able to treat skin of any color safely.