When one is choosing an arsenal for smooth, clear, youthful skin – laser therapy may your best bet for Weapon of Choice (WOC). Religious sunscreen application, a daily skincare ritual and good genes aside, if you’ve seen enviable skin on a woman older than 40, you can bet that a laser encounter is lurking somewhere in her past.
So, where does one start when considering a laser procedure? The answer to this question is quite simple.
Choose someone who knows EXACTLY what he or she is doing.
You will need someone with considerable experience in performing the procedure, someone who has a vast knowledge of the technology, someone who understands which laser will work best for the desired outcome and someone who has a wide range of lasers readily available for use.
In short, to use a Star Wars analogy, you will want Obi Wan Kenobi. When your face is the target and a light saber-ish device is the WOC, even Luke Skywalker might be too much of a renegade for the job.
For those who live in the Nashville area, you might be pleased to learn that you’ve had a Jedi-Master in your midst, all along.
Dr. Brian Biesman trained in Oculoplastic, Orbital, and Reconstructive Surgery at the prestigious Manhattan Eye, Ear, and Throat Hospital and is Clinical Assistant Professor at Vanderbilt University Medical Center. He is a former President of the American Society for Lasers in Medicine and Surgery. In 2016, he was the recipient of ASLMS Excellence in Education Award. His list of awards and honors, while extensive, pales in comparison to the his list of research and clinical trials in the field of aesthetic medicine – in particular laser therapies. It is difficult to find a laser technology in the aesthetic mainstream that he has not had some part in researching or developing.
We are pleased to have some time with Dr. Biesman to discuss the often confusing world of laser therapy.
How did you get interested in lasers? UltraPulse was just coming out. In 1993 I finished my training, it came out in 1994, and quite honestly, I had the time to do it. I was practicing in Boston. There were a lot of good surgeons there. I was looking to find a niche. I started getting into lasers and was introduced to Jeff Dover in 1994. Jeff and I did our first laser course together in early 1995 and I got interested and involved. As new technology became available, I kept up with the technology and had relationships with vendors. As some of them would come up with something new, I’d get involved with their new products.
Can you talk a little bit about the different types of lasers, such as the difference between fractional, ablative and non-ablative? The whole goal of pretty much any laser-based technology is to create some type of injury. As a result of that injury, we either accomplish the critical objective, such as sealing a blood vessel or causing an injury to a brown spot that then peels off, or else we’re inducing a controlled injury to the skin and asking the body to heal that injury. As a result of the healing process, we are hoping to accomplish one of any number of objectives. It might be to improve skin texture or it might be to improve skin quality, in the case of scarring or photo-aging. It might be to reduce wrinkles or it might be to induce tightening or lifting in the case of some technologies such as Ultherapy – which is not a laser but a focused ultrasound device. The whole concept underlying any of these devices is to create an injury to a target in a controlled fashion. When it comes to all of these distinctions – fractional, ablative, and non-ablative – it’s all just a variation of what kind of injury are we creating, how much wound healing is required for recovery, and what type of wound healing we’re asking the body to do.
In the case of non-ablative, it means you’re not removing any tissue. You’re basically telling the body that you want it to remodel the skin. Whether it’s remodeling a scar, or remodeling some photo-aged skin, you can get improvement in skin quality and texture without creating a wound that requires a longer time to heal. There is a limit to how much the body can do with a more limited wound.
When you get into ablative – which means removing – the body needs to heal a more significant wound than is created by a non-ablative laser. With traditional resurfacing, we remove the entire outer layer of the skin and part of the next layer down – the dermis. We therefore leave a large layer of tissue that will remodel itself and tighten. Traditional resurfacing thus involves tissue removal as well as induction of extensive remodeling. The process works very effectively and we still use it at times. The downside is the length of recovery and the somewhat higher potential for side effects and complications relative to fractional techniques.
The fractional concept is one that suggests we’ve got areas of tissue which we are treating with laser and other areas we’re not touching at all. We do fractional treatments in which we treat a very small percentage of the skin and we can do fractional treatments in which we treat so much of the skin that it’s basically the equivalent of a full resurfacing treatment because we’re causing a very extensive injury.
The surgeon’s job is to determine the underlying condition that needs to be treated and then figure out what device is going to deliver enough injury to accomplish the objective, but the least amount necessary so that recovery time and risk are kept to a minimum. If you are a 35 year-old that has a little bit of wrinkling and discoloration, you don’t need the same type of procedure as someone who’s spent their life in the sun and decides on their 70th birthday to do the first thing they’ve ever done for themselves. It’s going to be two very different types of injuries you need to create, and we now have the capability of creating a full spectrum of injuries – from those that require really no downtime from a work or social standpoint, but with a less dramatic result to those which are going to give you substantially more improvement. But as we say, there’s no such thing as a free lunch. The more aggressive the treatment, the more remodeling you’re going to induce, the more improvement you’re going to get, but the longer the recovery and the higher the risk.
When you say fractional, are you saying that with each pass there are some areas not affected by the laser? Imagine a grid of spots, like you’re playing the connect-the-dot game and you draw in that little line between the dots, that’s what a fractional resurfacing laser does. These little dots represent small areas of injury to the skin. We can vary how close injuries are to one another, or how far they’re spaced, as well as the depth of injury created at each spot. Depending on how much change or improvement we need to make, we’ll adjust the device settings accordingly. You can have two patients both undergo a fractional treatment, but one might have a very easy-breezy, short recovery because they didn’t need that much in the way of improvement, while others will undergo a much more extensive treatment that has a much longer recovery. Fractional is thus a relative term. It means less than full, but there’s a wide range of what percentage of the skin’s surface we’re going to cover with a fractional treatment.
What is the difference between a CO2 and an Erbium laser? There are three laser wavelengths that are used in ablative fractional resurfacing – CO2, Erbium:YAG, and Er:YSGG. They’re all absorbed by water, and each has slightly different absorption characteristics. In the hands of an experienced surgeon using a good quality laser emitting at one of these wavelengths, excellent results can be achieved. A successful outcome depends more on the surgeon than on the actual wavelength of light used.
How do you make the determination as to which one you’re going to use? A lot of times, it’ll come down to practical considerations related to features unique to each device. The biggest message that would be a benefit for patients is to not get caught up in the fact that there are fine differences between these lasers. It’s a bit like worrying about which engine does a BMW use versus a Mercedes. If you want to get into that, you can, but unless you’re a mechanic, it’s not going to mean anything. Consumers need to find a surgeon who understands these things, one who has the technology available to help accomplish their goals, and to understand that when looking for someone to perform laser treatments and/or injectables, the same level of homework should be done as would be the case if they were undergoing surgery. Unfortunately, many consumers make decisions about non-invasive medical care based on factors such as location, parking, or cheap costs. All of these are issues that would be of secondary importance if it came to researching a surgical procedure. The real message is that there are a tremendous number of variables and there’s a lot of expertise that’s required both in the decision making process and the technical delivery of these procedures. That’s where people need to do their due diligence with respect to a surgeon, as opposed to thinking, “It’s not surgical, it doesn’t matter as much.” Find someone who’s experienced and knows what they’re doing.
What is your go-to laser for laxity and wrinkles? If the cases are severe, we’ll still do full ablative resurfacing with CO2 laser. I treat the vast majority of laxity and wrinkles with some type of ablative resurfacing, Active and Deep Fx is one example. We treat the entire surface as well as creating fractional injury deep into the dermis to get some tightening. Recovery time is about a week. After full ablative, 10-14 days of recovery are required.
While treating for wrinkles and laxity, will you also get any changes in brown spots, or melasma as well or is there a whole different kind of laser you use when treating dark spots? Laser resurfacing will help with brown discoloration and age spots. Melasma is not something that’s best treated by lasers period, even though there are lasers that have indications for it. Melasma cannot be cured. Occasionally we will use lasers in conjunction with medications as a sort of last resort, but laser is really not, in my opinion, a good first treatment for melasma. You’ll pay a lot of money and your melasma is going to come back.
The younger generation sees their freckles as attractive and youthful. How do you make skin appear younger without getting that “plastic” look? Freckles come back. You can definitely treat people for photo-aging, but their freckles come back.
What do you do when someone comes in and their main concern is their age spots? It depends on what the background setting is. If there’s not much sun damage, then we can treat the brown spots locally with Q-Switch lasers, Picosecond or nanosecond. They can treat brown spots very effectively. The same type of laser that we’d use to treat a tattoo. Intense Pulsed Light (IPL) can also be used in some patients to treat brown discoloration.
Concerning nanosecond and picosecond, is it just about how quickly the pulse is delivered? The difference between nanosecond and picosecond lasers is how quickly the pulse is delivered. Picosecond is the shorter pulse duration. The idea is to deliver very short, extremely high energy bursts of laser energy that can do a number of things including improving skin quality, and removing tattoos and brown spots. PicoWay, Enlighten and Picosure are lasers that use picosecond technology.
What about treatment of unwanted skin redness? How we choose to treat unwanted redness depends on whether the redness is the only issue or if brown discoloration is also present as is frequently the case. If red and brown discoloration are both present, we tend to do IPL because it will address both concerns. If unwanted redness alone is the major concern, we’ll use a vascular laser such as the VBeam pulsed dye laser. However, if someone says, “I’m fine all the time, but when I exert myself or have a glass of wine, or a hot shower, my face gets flushed,” we advise those patients that their redness is related to a neurogenic response and that they may or may not improve much with laser treatment. If someone is red all the time and has “flushing”, their baseline redness can be expected to improve but their flushing may not change. If their only concern is flushing, we do not set high expectations for improvement following laser treatment.
Can you treat vessels around the nose? You can. I prefer to use a long pulsed KTP or Nd:YAG laser. It depends on the size of the vessels. These vessels tend to respond beautifully to laser treatment but patients need to be aware that at some point in the future they will develop additional vessels in this area.
When do you use chemical peels instead of a laser and how do lasers compare to a deep chemical peel? The skin doesn’t know if it’s being injured thermally, mechanically or chemically. It’s about the depth and extent of injury you create. If there’s someone who’s an expert chemical peeler who feels they can judge the depth of injury better with chemicals than lasers, then more power to them. The aspect I like about lasers is that the physics of the device and the physical properties of the light and the way it interacts with our tissue allows us to have a tremendous amount of control over the extent of injury we’re creating. Once scenario in which a chemical peel have enough contrast in color between the sun damaged area and the background area, it’s harder to sometimes get as good of a response. Lasers are looking for that darker color. Chemicals aren’t looking for color. They’re interacting with the skin. There are times when we’ll do chemical peels in lieu of laser treatments if we feel there’s not enough contrast.
Why do you need to be careful when using lasers with darker skin? A couple of reasons. The primary reason is when you create an injury in darker skin, as it heals, it has a tendency to turn temporarily darker. That darkness can be quite pronounced and it can take time for it to resolve. Another reason is relative safety, as some lasers that can be used safely in lighter colored skin can cause injury to skin of color if not used correctly.
How do you address acne and acne scarring? Do you use lasers? First-line treatment of acne, in my opinion, is medical therapy. That said, laser treatment can be used to kill the acne bacteria and to treat the redness associated with acne lesions. We will sometimes use vascular lasers to help reduce redness for patients who are having active breakouts. We also sometimes use PDT (photodynamic therapy) treatments for patients with acne, and that not only helps target the glands that play an important role in acne, but also kill acne bacteria.
When it comes to acne scarring, there are several different types of scar. It follows logically that more than one type of treatment may be needed to achieve best outcomes when treating acne scars. For treatment of moderate to severe scarring my first go-to is typically surgical. Many practitioners don’t recognize the value of surgery, but in my experience, extensive subcision is an extremely effective treatment for patients with mild to severe rolling scars and some patients with boxcar scars. I think acne scarring is something that clearly requires surgical capabilities with the exception of only the most mild cases. Milder cases of acne scarring may be treated with lasers and/or microneedling. There are also times when we’ll use injectables under acne scars, either as a temporary or long-term solution depending on the scars. But again, I frequently use surgical procedures first in many cases unless someone has such mild scarring that I believe laser treatment or other nonsurgical treatment would be sufficient.
Can you talk a little about ultrasound devices? Are these “lasers” and how do you use them? Ultrasound devices are not lasers. Ultrasound devices use focused sound waves to exert a clinical effect, whereas lasers use light energy to achieve clinical benefits. Ultherapy is the name of a treatment delivered by the device that uses focused ultrasound to induce lifting and smoothing of skin. It is the only technology to have an FDA indication for non-invasive skin lifting, specifically of the brows and the skin in the submental region. It also has an indication for reducing wrinkles in the decollete region. We use Ultherapy in patients with whom we’re trying to achieve a visible lift without surgery. Ultherapy can be thought of as a fractional technique because it delivers little points of focused ultrasound that are separated from one another but does not produce confluent heating beneath the skin. Thermage on the other hand heats the skin in a uniform manner so that there are no skip areas. It gives contouring by delivering heat to the deeper layers of the skin in a uniform manner. This induces tightening of existing collagen, as well as production of new collagen which not only leads to improved contouring, but which also plays a very important role in helping skin stay youthful in appearance.
I have a number of patients in my practice who I’ve been taking care of for years, who look better today than they did 10-15 years ago. I feel confident today telling patients that, as long as they maintain a relatively healthy lifestyle, using a combination regular treatment with injectables, skincare, periodic skin tightening and resurfacing, we can keep them looking their best in a natural way for 10-15 years or more in most cases. I do believe in using aesthetic treatments for maintenance and prevention as well as correction.
When you see clients in your office, how do you decide which combination you’re going to use for injectables, toxins, lasers, or when do you say it’s time for surgery? Each patient is unique and different. In most cases, the question is not, “Should I have a laser, have injections, or undergo surgery?” as these treatments all achieve different objectives. We use surgery to pick up something which has fallen down or to remove something which is present in excess quantities. We use non-invasive techniques to improve color or texture. The only potential overlap may be in something like Ultherapy where you’re trying to get a bit of lifting or some contouring, but honestly, if someone starts using their fingers to pick up on their eyebrows or their jowls to indicate their treatment goals, they probably need to have a surgical procedure. If you’re looking for so much change that you have to use your fingers to move your face to demonstrate it, you either need to have surgery or modify your expectations. If someone expresses an interest maintenance or achieving more modest changes, and they understand they’re not going to get as a dramatic change as they would with surgery, then we can talk about other potential options for them.
Is there anything you do to get someone ready, when you know they eventually are going to need to have surgery? Usually, it ends up coming down to logistics and practicality. From a procedural standpoint, I try to choose whatever operation is going to make the biggest, most noticeable change, that is likely to meet their needs, and which has a favorable risk/benefit ratio. When it comes to preparations, it doesn’t make any sense to inject a bunch of filler two months before someone’s going to have a facelift because you have to dissect in those same areas and the filler probably won’t be effective after surgery. Sometimes patients are just unhappy with their overall appearance but have difficulty communicating what really bothers them most. I proceed with caution in these situations and usually take a conservative approach initially. While they may be candidates for multiple different procedures, once you start making them look better in even one or two areas, all of a sudden they may start to feel better about themselves and may decide to hold off on undergoing surgery.
If someone asks you what to do in their 30s, 40s, 50s to look younger, what would you say? In your thirties – it’s always skincare, sunscreen, noninvasive skin tightening, and possibly reversing photodamage. Often people in this age bracket will start using Botox or other neuromodulators and may begin undergoing noninvasive skin tightening treatments. In the 40s, I recommend skin tightening, treatment of photoaging, and regular treatment with injectables. Skin resurfacing often becomes necessary as well. If you start early, you need to do less as you age. If you’re talking about someone in their 40s and 50s, if they’ve never done anything before, it may take a bit more work to get people to where they want to be. People in this category may need to undergo injectables, skin tightening, resurfacing or even surgery in addition to skin care, sunscreen and other preventative measures. The 50 year-old who started doing things when she was 35 has a different set of needs than someone who is the same age who has never done any rejuvenation treatments. Prevention is key – I never believed it until I saw it in my own patients.