Lasers, Fillers and What to Expect from a Cosmetic Procedure (podcast)

The last 15 years have really changed the way we look at lasers and who performs the surgery. So before, say, 1999 or 2000, lasers were largely confined to physicians who would do very small procedures, often times not cosmetic. Again, a lot of pediatric problems with birthmarks and port wine stains and then maybe broken blood vessels in adults.

But what really changed laser medicine was laser hair reduction, and that was one thing. The second thing was full-face rejuvenation with an intense pulse light device. So those two types of devices and those two types of procedures fundamentally changed the way lasers and light devices were used in cosmetic dermatology.

No longer were things done only by physicians in small regions [of the body]. Now procedures were done over a large area, say a whole back for hair reduction or perhaps a whole face for red and brown spots in a single session with larger, more efficient devices.

Wrinkles are tough because it depends on what type of wrinkle. So the wrinkles that people typically have between their eyes and around their eyes, we treat with what's called a neuromodulator and there are three brand names of that. The most well known is Botox, and there are two others, Xeomin and Dysport. And they're really the best, safest medicines that we can use for those wrinkles.

For lower face wrinkles, we have two major things we use. One is laser. It's usually a laser that tightens the skin and the second thing are called fillers. And fillers are like materials that we put into the skin to lift it a bit and also fill little lines and they're either gels or clear gels that we put in and they last about a year.

A very noninvasive laser that we might use, for example, just to remove red and brown spots normally does not do a whole lot for any wrinkles. On the other hand, we can do a deep laser peel with what's called a carbon dioxide laser, and that will eliminate or help many wrinkles. Not so much the wrinkles around the eyes but the wrinkles particularly above the mouth.

It depends on the type of scars, but normally when people have acne scars, the first thing we do is we stop the acne. Many people come in and still have active acne. So we try to stop any active acne and then we talk about two big choices.

One choice is a more aggressive procedure, which is an open wound, where you have to take seven or 10 days off. The other is what we call a non-ablative laser where you just look sunburned afterwards.

The ones that are non-ablative or less invasive typically do not achieve as good results, but they're often times more acceptable to patients because patients have things to do. Many patients would rather do two or three sessions with a more gentle laser and return to work or social or school activities very quickly rather than take a week or a week and a half off.

Spider veins are addressed two ways. Normally we combine two therapies. One is called sclerotherapy where we inject a solution into the vein through a small needle, and the other is laser therapy where the laser simply vaporizes the vein and makes it go away.

For 95 percent of what we do, the patient simply receives a numbing cream. We put a white cream on the face for normally 45 minutes. We go through what we're going to do. We take photographs, and after that time, we take the cream off and then we have the patient lay down just in a normal, kind-of-sitting-on-your-couch or laying-on-your-couch position. We take all the cream off, as I said, and then we just apply the laser.

Most of the procedures we do take about 10 to 20 minutes. They're not long procedures.

The size of the laser beam is oftentimes as big as a half dollar or quarter, and we fire that laser often times every second. So you can cover a lot of ground very quickly. Particularly if we're doing a chest or a back, that's important to cover some ground.

It varies. It depends on the person. It also depends on what you're doing. Some procedures are so painful, we actually have to give you a numbing shot. Like a deep laser peel, we have to give you some numbing injections. We normally give you a little sedation. You're awake, but you're mildly sedated. We blow cold air on the skin, and we also use the numbing cream.

For a bigger procedure, we do a lot more than we do for a smaller procedure, but 95 percent of what we do is just Tylenol, some numbing cream and we go at it. It takes about 20 minutes. You're a little red or pink like you would be after getting a sunburn. You hop back in the car, turn your air conditioner on, blow all the air to yourself, and by the time you get home most of the pain is completely subsided.

Almost everything we do, 98 percent of what we do in laser dermatology, we're heating something. It's heating. So we're normally applying a laser beam, and that laser beam is converted to heat. So we're taking light and converting it to heat, and it hurts. It's a very short, snappy pain for most procedures. And the pain typically endures for about 30 minutes afterwards, and it subsides very quickly after that.

For some procedures, you can go back to doing whatever you're doing. If we're treating, say, a birthmark, a red birthmark, we may get just some redness or some sunburning.

We tell people whether they should or should not get in the sun. If something's an open wound, we normally have them obviously not go to the beach or do something like that and try to stay indoors as much as they can and away from people. But most procedures are intermediate. They get a little crusting where they have brown spots. They have a little swelling. They have a little redness, and we really leave that up to the patient.

Most patients can do whatever they feel they can do comfortably. So what I mean is some patients are working in a job in a cubicle. If you're a 911 operator, for example, you could go back and do a lot of these procedures and sit in your office and respond to calls and nobody would know the better. If you're a newscaster or a big salesperson and you have a very big sale coming up, you would want to wait until every last crust came off, even if it was subtle, because some people might just be a little put off by their salesperson having crust coming off their skin.

It depends on what they come in with. If somebody comes in with red or brown spots, I love that because it's easy to treat. We can use lasers that are very selective and only treat the red and brown. For wrinkles, it's a little more challenging, but almost any patient who has something that they don't like, for the most part we can reduce or diminish with laser. Excessive hair, as long as it's dark. Birthmarks, red or brown. Even melasma [patchy brown, gray-brown skin discoloration] we can treat to some degree. Wrinkles, freckles, broken blood vessels, rosacea. There's a whole list of things that we can treat. So almost anybody is a candidate for something with laser.

There are a lot of things that have been suggested for lifting the skin or tightening the neck and one product is called Kybella. Kybella is a chemical that's injected into fatty areas. It's only FDA-cleared right now for the neck. It's really not for tightening; it's for fat.

A turkey neck would require more than Kybella. So most people really are not good Kybella candidates because most people don't have fat necks; they have loose necks.

So for the fat necks, Kybella works quite well. It kind of resets the contour of the neck. So some people have that neck where it goes straight from their chin to their heart basically. There's no angle, and what Kybella can do for those fatty necks or submental fullness, as we call it, where people get full necks, Kybella can reverse that by dissolving the fat.

About 25, 30 years ago we developed these lasers called quality switch lasers or Q-switch lasers, and they've really evolved to treat tattoos because they have very short pulses. Their pulses are so short, they're called nanoseconds. And when the pulses are so short, the heating of the tattoo particle is very specific. In other words, we're just heating the tattoo particle under the skin, and the good guy, which is your normal skin, is spared. So that's why we can get nice results.

The problem with laser tattoo removal, even now when we have even shorter pulse lasers, is the colors. Black tattoos respond very well to laser tattoo treatment but other colors like blue, green, purple, yellow, flesh-colored tattoos, they often times don't respond predictably well. So the biggest factor on how a tattoo is going to respond to a laser that's dedicated for tattoo removal is the color of the tattoo.

It really depends on what we're treating. For static little brown spots on the arms, hands, face, I'd say 95 percent success rate. Broken blood vessels on the nose for elderly men or even women, very high success rate, 80 or 90 percent. Skin tightening, not so high because it depends on where you put the bar. It depends on where you declare success. For me, success is an 80 to 90 percent improvement. Some patients it's 100%, and some patients it's 50 percent.

So most patients are pretty happy and they're reasonable people. And if they get 80 or 90 percent improvement, they're happy with that.