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Surgery and Cosmetics

James M. Spencer, MD, MS

Lessons Learned from Lasers Past

James M. Spencer, MD, MS

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 drugs.  
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 experience?
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 may ensue.

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 toy.
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 trials.
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.