Lessons Learned from Lasers Past
Tuesday, April 08, 2008
Those with a cosmetic practice are always under pressure for the
"latest and greatest" innovation. Beauty magazines describe new
techniques to their readers as soon as they are proposed. Cosmetic
practice is highly competitive and practitioners most often are
looking for a way to stand out from the crowd. Furthermore, I think
doctors, like many people, like novelty. This tends to push them to
adopt new technologies that may not be completely proven or
developed. Nowhere is this more obvious than in the use of lasers.
Regulation of devices requires proving safety and less evidence is
needed regarding efficacy of devices compared with
Remember just a few years ago when CO2 laser resurfacing came out?
This magic procedure was the focus of every educational meeting for
Dermatologists and Plastic Surgeons alike. Doctors clamored to
attend weekend courses so they too could start facial resurfacing.
How many lasers were sold, in excess of $100,000 each, that are
sitting in corners now? What can we learn from this
First, let me say that CO2 laser resurfacing, when properly
performed and for the right patient, is a fantastic procedure.
There is nothing like it for deep rhytides on loose facial skin.
However, it has a number of serious drawbacks. It is a truly
invasive procedure that produces a significant facial wound that
requires wound care and quite a bit of hand holding from the doctor
and medical staff. No matter how much preoperative counseling is
given, many patients are truly alarmed by the wound. This is a huge
stress not only on the patients, but on their physician and his or
her staff. The acute wound healing phase is only a week or so, but
it can be a really long week. The patient can have up to 6 months
of persistent erythema, so that much more stress and hand holding
Although it is a safe procedure when properly performed,
complications can and do occur. Scarring, infection, and
dyspigmentation are very real. The procedure became so popular so
quickly that poorly trained practitioners in fields other than
dermatology adopted the technique with disastrous results. This
gave laser resurfacing very bad publicity. Finally, in a
development no one could have foreseen, it became apparent later on
that up to 20% of patients developed permanent hypopigmentation 1
year or more after the procedure. For a variety of reasons, the
popularity of this procedure has waned.
So what lessons may we draw from this experience? First, we should
remember that there will always be the newest laser, filler, or
cosmetic technique; however, novelty is no reason to adopt a
technique. Doctors must beware of fads. Of course we should be open
to innovation, but an advertisement in a beauty magazine is no
substitute for rigorous clinical trials. New techniques should be
adopted slowly and with caution.
Next is the importance of proper patient selection. Patients who
have dramatic results from the procedure will gladly go through the
difficult wound healing process and whatever expenses are needed.
However, if they do not have a dramatic result, you will have a
seriously disappointed patient on your hands. At the height of its
popularity, I believe laser resurfacing was over utilized. Patients
better suited for other techniques received laser resurfacing
anyway. Careful patient selection requires experience and objective
evaluation of the procedure, not a rush to use the latest
Lastly, doctors should await long-term results before adopting new
procedures. Permanent hypopigmentation in up to 20% of CO2
laser resurfacing patients did not manifest until a year or more
after the procedure was done, so those who jumped on the bandwagon
early had completed many cases before this side effect presented.
This could not have been appreciated from the preliminary
Since enthusiasm waned from CO2 laser resurfacing, we have seen a
plethora of "nonablative" lasers come and go on the market for
facial rejuvenation. The latest arrival is fractionated
resurfacing, with devices selling well in excess of $100,000. Are
these really the ideal solution for rejuvenation? Are we wise to
invest in such an expensive purchase? I think the lessons learned
from CO2 lasers can help guide us.