One Laser for a Cosmetic/Dermatologic Practice

Message from the Section Editor
As the Section Editor of the “Aesthetic Update” section of The Journal of Clinical and Aesthetic Dermatology (JCAD), it is my extreme privilege to introduce a new series of guest submissions. We have invited some of the leading experts in aesthetic dermatology to contribute to the Aesthtic Update in 2011, and each one of them has been tasked with writing a commentary based on their experiences in a specific field or writing a review of a topic for which they feel passionate. I hope you find this Special Section interesting, stimulating, and provocative—and I welcome your comments on these cosmetic and aesthetic topics.
The first of our “guests” is a well-known dermatologist and laser and energy source expert—Mitchel P. Goldman, MD, FAAD, FAACS. Dr. Goldman has been extensively involved in lasers and light source technology for many years and has researched and published on many of the various technologies that exist today in both therapeutic and cosmetic dermatology. Dr. Goldman’s dedication to excellence and his pursuit of the truth behind the energy devices with which he works has resulted in an enormous depth of knowledge in this arena. To that end, our first guest submissiom addresses perhaps the most widely asked question among laser surgeons—if you could only buy one laser or light source, which one would you purchase and why? Dr. Goldman explores this topic as expertly as anyone can, and it is my hope that you enjoy reading this commentary as much as I have.
—Michael H. Gold, MD

One Laser for a Cosmetic/Dermatologic Practice
Mitchel P. Goldman, MD

Dr. Goldman is Volunteer Clinical Professor of Dermatology, University of California, San Diego, San Diego, California.

If you could only buy one laser, which one would you purchase and why? This is the most common question my colleagues ask me. To address this question, I must first begin with the disclaimer that I am or have been a consultant for, lectured for, performed workshops for, and/or received discounted equipment and/or research support from many different laser companies including Lumenis (formerly ESC and Coherent), CoolTouch, Cutera, Cynosure, Candela, ConBio, Sciton, and Syneron. I have also been instrumental in the development and initial clinical testing of the pulsed dye laser; Q-switched alexandrite laser; Ultrapulse CO2 laser; intense pulsed light (IPL); long pulsed 1064nm Nd:YAG Vasculite and CoolTouch Varia and CoolTouch I, II, and III; Affirm Multiplex; and eMatrix. My practice also presently owns 38 lasers from all of these companies and others that are used every day. With this background, one can see that my answer may upset the majority of laser companies, but the question is valid and deserves an answer. The answer reflects my personal opinion, and different answers from other experts might be equally as correct.

One can argue that almost any laser can be used to treat a variety of conditions by changing various parameters of the laser or using the laser in conjunction with some other technique, such as epidermal cooling, dying an epidermal lesion a certain color, or applying a chemical that is photoactivated.[1] If this was true, the least expensive laser would be the one you should buy. However, if you wish to be a bit more specific and acquire a specialized laser, which one is best? The answer to this question depends on the type of practice you have (i.e., cosmetic, general dermatology, hair removal practice/spa, or one dedicated to phlebology).

Cosmetic Practices
In a cosmetic practice, noninvasive rejuvenation and laser hair removal are perhaps the two most popular procedures. In this setting, my choice of laser is an intense pulsed light (IPL) laser. Only an IPL can treat both superficial vascular and melanocytic lesions, generate collagen stimulation, and affect hair removal. The IPL can be manipulated so that many different wavelengths can be produced along with an infinite number of combinations and lengths of pulsed durations. The IPL can therefore be targeted to many different sizes of blood vessels, pigmented lesions, and hair follicles. Other vascular lasers, such as the pulsed dye lasers and long-pulsed 532nm neodymium-doped yttrium aluminium garnet (Nd:YAG) lasers, can do a great job of eliminating vascular ectasia and telangiectasia as well as possibly some lentigines through nonspecific thermal effects when used without epidermal cooling, but they cannot treat hair.

Another benefit of IPL and vascular-specific lasers is the ability to soften superficial wrinkles. Some physicians believe that collagen stimulation can occur through irritation of endothelial cells lining capillaries with release of growth factors or through direct stimulation of fibroblasts. I have not been significantly impressed with minimizing wrinkles or striae with any vascular-specific, pigment-specific laser or IPL, but do not entirely discount the opinions of these experts. In my opinion, published studies have not looked long enough at treated patients to accurately evaluate wrinkle resolution since collagen remodeling may take nearly a year to occur. In my practice, it is common for both the patient and me to be less than enthusiastic with the treatment of his or her wrinkles only to be surprised when he or she returns a year later looking better. I choose the IPL as the one best machine because it can treat both vascular and pigmented lesions as well as hair and perhaps collagen remodeling. Unfortunately, all IPL machines are not equal. Very few have the ability to produce multiple sequential pulses. Very few allow the user to vary the fluence independent of the pulse duration. The ability to vary the pulse duration and fluence independently allows for more selective effects on pigmented or vascular structures. In my practice, we have found that excellent results only require one or two treatments, and we never offer the patient a “series” of treatments.[2,3]

Does this mean we should all discard our vascular- and pigment-specific lasers and purchase IPLs? No. If you have another laser, I would recommend that you use it as described to the best of its abilities. The concurrent use of lasers and topical products containing growth factors, retinoids, and antioxidants may improve treatment outcome. Injection of blood, producing dermal damage through mechanical needling, generates a vascular target for the laser to aid in production of new collagen. Painting or marking a pigmented lesion with vascular-specific ink may also allow nonspecific thermal ablation of superficial lesions. Other “tricks” will likely be developed to enable a laser with an initial singular function to treat vascular, pigment, benign epidermal lesions, collagen/fibroblasts, and possibly hair through dyes or photodynamic medications.4

General Dermatology Practice
In a general dermatology practice, the treatment of superficial skin cancer, warts, and benign epidermal growths is common, and my choice of laser would be an ablative laser. Ablative lasers currently available are either confluent or fractionated CO2 or erbium-doped yttrium aluminium garnet (Er:YAG). Both confluent lasers will vaporize lesions. Fractionated CO2 or Er:YAG will do so with minimal nonspecific thermal damage. Continuous wave CO2 lasers will produce nonspecific thermal damage. Ultrapulse and/or millisecond domain lasers can vaporize with a minimal amount of thermal damage. Techniques can be used to minimize nonspecific thermal damage, such as super-hydrating the skin or using a low-density pattern and/or the minimal vaporization energy. However, the CO2 family of lasers will always give more nonspecific thermal damage than the Er:YAG group of lasers.[1]

There are three forms of Er:YAG lasers. The standard, micropulse Er:YAG lasers leave the least amount of nonspecific thermal damage with the downside of nonhemostasis. Long pulsed or variable pulsed Er:YAG lasers function like both the standard Er:YAG as well as the Ultrapulse or millisecond CO2 lasers. The advantage here is that hemostasis can occur on one pass with a change to pure vaporization with another pass at different settings. Finally, fractionating the Er:YAG laser can produce rejuvenation effects as well as minimize the appearance of scars.[5–8]

Hair Removal
If you wish to open a hair-removal practice, there are a number of different systems to consider. All laser and IPL systems have been demonstrated to have similar efficacy in hair removal. Depending on your patient population, shorter wavelength lasers (ruby, alexandrite, and 810 diode) work best for lighter skinned patients. Darkly pigmented patient populations will do best with long-pulsed Nd:YAG lasers. Although super-long (100msec) pulses of alexandrite and 810 diode lasers have been reported to produce hair removal in dark-skinned populations with minimal epidermal damage, that is not guaranteed. Expert technique is required to achieve optimal results in this patient population. The advantage of long-pulsed Nd:YAG lasers is that they can also be used easily to treat hair in dark-skinned populations and be used to treat vascular lesions in all populations. They also have the potential for collagen stimulation.

The advantage of shorter wavelength systems is their ability to treat epidermal pigmented lesions. The advantage of using an IPL machine in hair removal is its additional use as a photorejuvenation machine with treatment of vascular and pigmented lesions as well as the potential for collagen stimulation.[9,10]

In a phlebology practice, the treatment of leg telangiectasia resistant to sclerotherapy is the most important condition one will encounter. Although almost any vascular-specific of IPL lasers can be effective, the 1064nm long-pulsed Nd:YAG lasers are my choice. A review of the literature on these lasers shows almost equal efficacy between them. I would therefore choose the one machine with the most versatility in terms of spot size with the most efficient epidermal cooling system. The long-pulsed 1064nm Nd:YAG lasers are also very useful for hair removal, especially those machines with a large spot size, efficient cooling mechanism, and rapid repetition rate.[11,12]

My reason for not choosing other pulsed dye lasers or long-pulsed 532nm Nd:YAG lasers for leg veins is that these machines require exceptional skill by the operator to avoid excessive epidermal damage. In addition, my experience has been that these lasers produce long-lasting hyperpigmentation more frequently than long pulsed 1064nm Nd:YAG lasers.
The one class of lasers that I have chosen not to discuss are Q-switched lasers (ruby, alexandrite, and Nd:YAG), which were originally developed for the treatment of tattoos. This is because the treatment of tattoos is not very profitable in and of itself. Patients who want their tattoos removed are not always capable of spending the time or money to have their tattoos completely removed. Laser tattoo removal usually requires 6 to 12 treatments every few months and costs many times more than the actual tattoo. My colleagues in my cosmetic laser dermatology practice and I are presently evaluating a new technique of treating a tattoo multiple times during a single session. The advantage to this technique is better efficacy; the disadvantage is that treatment times can be more than one hour, as the patient needs to wait at least 20 minutes between each laser treatment. Unfortunately, there may be an increased incidence of hypopigmentation from this multiple treatment technique.

The profitability of owning a Q-switched laser is in the treatment of epidermal pigmented lesions. Solar lentigos can be effectively treated with any of these lasers as can dermal pigmented lesions, such as Nevus of Ota. If your practice population is skewed toward this population (usually Asian and/or photodamaged), then one of these lasers should be considered. My recommendation for a Q-switched laser is the Q-switched alexandrite laser because this 755nm laser has good absorption for both epidermal and dermal lesions. It also is more gentle (longer pulse duration, 60–100msec) than the Q-switched ruby (24–28nsec) or Nd:YAG lasers (4–6nsec) that will minimize epidermal damage especially for darker pigmented patients.[13]

To summarize, when deciding which laser to purchase for your practice, you must first consider the type of practice you have or want to have as well as your patient population. Many lasers can be used for more than one purpose. Ancillary techniques (such as dying lesions with ink or producing dermal extravasation of red blood cells) can also expand the utility of lasers from one lesion to another. These factors along with creativity will lead to the one best laser to purchase. However, keep in mind that having two or more lasers is always better.

1.        Goldman MP. Cutaneous and Cosmetic Laser Surgery. London: Mosby/Elsevier; 2006.
2.        Goldman MP, Weiss RA, Weiss MA. Intense pulsed light as a non-ablative approach to photoaging. Dermatol Surg. 2005;31:1179–1187.
3.        Nootheti PK, Pettit KA, Yosowitz G, Goldman MP. Clinical improvement of photodamaged skin after a single intense pulsed light treatment. Am J Cosmetic Surg. 2007;24:15–20.
4.        Avram DK, Goldman MP. Effectiveness and safety of ALA-IPL in treating actinic keratoses and photodamage. J Drugs Dermatol. 2004;3 (Suppl):S36–S39.
5.        Saluja, R, Khoury J, Detwiler S, Goldman MP. An evaluation of the histologic and clinical response to varying density settings with a fractionally scanned carbon dioxide laser. J Drugs Dermatol. 2009;8:17–20.
6.        Campbell T, Goldman MP. Complications of fractional CO2 laser, a review of 373 treatments. Dermatol Surg. 2010;36:1645–1650.
7.        Avram DV, Goldman MP. The safety and effectiveness of single-pass erbium:YAG laser in the treatment of mild to moderate photodamage. Dermatol Surg. 2004;30:1073–1076.
8.        Goldman MP. Laser resurfacing. In: Draelos Z, ed. Cosmetic Dermatology: A Comprehensive Medical and Surgical Text. Wiley–Blackwell; 2010:393–408.
9.        Rao J, Goldman MP. A prospective, comparative evaluation of three laser systems used individually and in combination for axillary hair removal. Dermatol Surg. 2005;31:1671–1677.
10.        Khoury JG, Saluja M, Goldman MP. Comparative evaluation of long-pulse alexandrite and long-pulse 1064 nm Nd:YAG laser systems used individually and in combination and 810nm diode laser for axillary hair removal. Dermatol Surg. 2008;34:665–671.
11.        Dover JS, Sadick NS, Goldman MP. The role of lasers and light sources in the treatment of leg veins. Dermatol Surg. 1999;25:328–336.
12.        Goldman MP. Laser and sclerotherapy treatment of leg veins: my perspective on treatment outcomes. Dermatol Surg. 2002;28:969–970.
13.        Fitzpatrick RE, Goldman MP. Tattoo removal using the alexandrite laser (755nm, 100ns). Arch Dermatol. 1994;130:1508–1514.