W hen it comes to lasers and cosmetic surgery there are some important distinctions to be made. For one the “lasers” used are not actual lasers but rather implements that heat up tissue without destroying it. There is an array of lasers and their respective uses, which range across the cosmetic spectrum.
Lasers for cosmetic medicine are broken down into two different categories: ablative and non-ablative. I'll discuss the primary differences these two, and also the various operations they are used for. I cover their role in regard to skin pigmentation, acne, skin aging and other great details!
In this episode, we cover:
Dr. Hall: Welcome to The Trillium Show, where we help you make the changes you want to see in your body, in your mind, and in your life. I'm your host, Dr. Jason Hall.
Dr. Hall: Hi, this is Dr. Jason Hall and welcome to another episode of The Trillium Show. Today we are going to talk about a subject which I have grown to love over time, which is lasers. Now, lasers are one of these areas in aesthetic medicine and surgery that kind of get a bad reputation because the category of lasers is so vast and so broad that people can have a laser treatment and say, “I had lasers and it really didn't work for me.”
And the problem is that unless you know exactly what type of laser that you had, it's very easy to say, “Well, it didn't work,” because just like in any other area in medicine, if you aren't using the right treatment for the right problem, you're not going to get a result that's anywhere close to what you were hoping for.
There are two main types of lasers: On one hand you have the non-ablative lasers; then on the other hand, you have the ablative lasers. Now, these two broad categories of lasers really do exactly what they say they're going to do. The non-ablative lasers do not damage the skin itself. The ablative lasers do; they ablate or destroy parts of the skin, and what parts of the skin they damage depends on what problems that we're looking to treat. So, I think before we really get into what the difference is between non-ablative and ablative lasers are, and what each one of those treat, we need to do just a really quick, like, 30,000 foot view of what lasers are and how they work.
Lasers and light treatments in general—and we're going to include IPL, or Intense Pulsed Light, or BBL, or Broadband Light in with the laser category—how light treatments work is they work by selectively heating tissue. And what tissues they heat really is dependent on the wavelength of light that we're using. The targets are known as chromophores, and there are three main chromophores that we talked about in aesthetic medicine: There is reds, or blood vessels and blood cells; there is browns, the pigment, so the melanin that's in our skin; and then there's water. And by selecting which one of those chromophores that we're going to target, we get different results based on that itself. So, not to get too detailed, to sciency, in any of this, but that's kind of a basic overview of what we are trying to do when we're talking about lasers.
So let's, kind of, get into the broad categories of lasers. And we'll start with the non-ablative lasers. With non-ablative lasers, the object is to obtain a result without damaging the skin. And with the non-ablative lasers—and again, we're going to include Intense Pulsed Light and Broadband Light which are not technically lasers, but thought of by the lay public as being lasers—what we are trying to do there is heat up tissue and change it without destroying.
So, we'll talk about indications first, and you can see how these different lasers work to accomplish what we want to. So, the main indications for non-ablative lasers are treating red pigment, treating brown pigment, hair removal, anti-aging, and acne treatments. How do the non-ablative—if we're destroying tissue, how do they work? Well, the mechanisms behind a lot of that aren't exactly known with reds. And when we're talking about reds, we're talking about things like rosacea, which is dilation of capillaries in the skin, typically along the cheeks; we're talking about broken blood vessels of the cheeks and around the nose and eyes. Those are little angiomas, but those are the things that we're talking about treating when we're talking about treating reds with laser or BBL.
The chromophore for that particular problem is the red blood cell, and so by using this light, we are heating the red blood cells and we're destroying the small blood vessels in the skin. It's important to note when we do that, though, that we're destroying the large blood vessels in the skin—or relatively large blood vessels that you can see that bother you—but we're not destroying all of them. And so there's a possibility that those vessels can come back somewhere else later.
With browns, which are another target chromophore, the pigment is another target chromophore of the light, what happens—and this is where the biology is kind of squirrely—is that we don't know exactly why it happens. But by treating the skin with light, the brown pigments—from sunspots, from some lentigo or birthmarks—can be lifted up to the surface of the skin, and they kind of flake away with time. Typically, that takes a few days for that to happen. What's interesting is that the melanocytes, or the pigment producing cells that are in the skin themselves don't go away, they're not damaged, and so they keep working. And that's why if you've ever had an IPL treatment for brown spots, we will treat those brown spots, but then once that flaking has gone away, we'll want to put you on a medication such as hydroquinone, which is an over-the-counter skin lightener, to turn down the production of melanin by those melanocytes in the skin to help prevent that brown from coming back because it will come back because we've treated the symptom, we haven't really treated the melanocytes which was a problem.
And you really don't want to damage the melanocytes, otherwise you start running into problems with hypopigmentation and white spots, which is, in this business, considered a complication. We've discussed treatment of red and brown. The third indication that we really need to discuss, and a reason that a lot of people seek laser treatment, is anti-aging. Now, this might be a little bit controversial with some people, but non-ablative laser's role in anti-aging medicine and skin rejuvenation really, is limited to maintenance treatments. These, in my opinion, are really not good treatments, if you are looking to improve lines and wrinkles, surface texture, they just don't have the power to do that in a cost effective way. You have to have a lot of treatments over a long period of time to get the same result with a non-ablative anti-aging laser as you would with an ablative single treatment laser.
So, the way that the anti-aging properties of non-ablative laser treatments work is very similar to the way that they treat reds and browns, which is heating, but heating deep into the skin, in the second layer of the skin, called the dermis, which is where the collagen lives. Heating that collagen will cause it to kind of uncoil and destroy it, and then your body goes back and tries to rebuild that. And by trying to rebuild that collagen that has been destroyed, it causes some thickening and tightening and new collagen deposition. Now, if you think about how that works, and after we talk about the ablative treatments, you'll really see that the ablative treatments just logically are superior in terms of collagen formation and wrinkle elimination, as well as just overall skin health.
That brings us to a discussion of hair removal, which is really probably one of the more common things that people hear about when you think about cosmetic lasers: Laser hair removal is kind of right up there. And the way that works is these lasers, again, heat their target to cause a change. So, in this case, the laser is heating the hair follicle by heating the hair and you heat the hair, you think of it as, like, a little wire that goes down into the hair follicle; that little wire gets hot, burns the hair follicles where the hair grows, and kills the hair follicle so the hair doesn't grow anymore. The problem is—and if any of you listening have had laser hair removal or know somebody who has, it takes a lot of treatments to get rid of the hair, and even then you don't get rid of all of the hair. That's because hair has a cycle, and only follicles that have a hair in them can get damaged. Not all the follicles do at any given time, so you're constantly chasing the hair cycle trying to get all of the hairs that are still around and treat those at any given treatment.
Lastly, and one of the lesser utilized non-ablative laser indications is for acne. Acne is one of those things that if you've got bad acne, it's really a problem. If you don't, you don't really think about it much. But acne can be really challenging and really frustrating for both physicians and patients to treat. Where the nonablative lasers role in acne treatment comes in is that we can use these lasers to heat the skin without damaging it, but can heat-kill the bacteria that live in the skin that cause the acne.
We can also use that same non-ablative heating, using a little bit different wavelength of light, to heat the surrounding tissue, causing new collagen formation and improving the appearance of some of the acne scars. This is one of those areas where a lot of laser companies like to sell it as though it's the best thing since sliced bread, but non-ablative laser treatments for acne scar treatment really are substandard when you have other ablative technologies out there, but it can help to minimize the amount of scarring that's there when we're actively treating the acne, as opposed to coming back after the fact, trying to clean up all of the scarring from untreated acne.
There in a very brief overview is non-ablative laser treatment. So again, our indications: Reds, browns, anti-aging, hair removal, and acne. And again, where the non-ablative treatments really shine is treating reds and browns, and hair removal. Those are the three indications that I think are most popular out there, certainly most popular in my practice.
So, let's talk about the ablative lasers now. And in a surgical practice, ablative lasers really are the workhorses. They get the best results of any of our other laser technologies, when it comes to treating a problem that we see. Again, maintenance, the nonablative technologies do a great job, but for treating fine lines, moderate lines and wrinkles, even deep lines and wrinkles, treating thinning skin, treating surgical scars, there really is no better option than an ablative laser.
There are two categories of ablative lasers that are important for you as patients to know about, and those are the fractionated ablative lasers and the non-fractionated, or full-field, ablative lasers. And we'll talk about each one of these.
So, fractionated ablative lasers are just what they sound like they only treat a fraction of the skin at a time. So, you can think about them. If you've ever seen a golf course or a yard that gets aerated, where they make those little holes so that they can fertilize the lawn. A fractionated laser works very much the same way. It uses laser light to make millions of microscopic little channels in the skin that go down into the dermis or the under—the second, kind of, deeper layer in the skin, and let your body produce collagen to help remodel the skin's surface.
That's why you can see thickening in the skin. That's why you can see remodelling of scars in improvement in fine to moderate wrinkles because what those wrinkles are are just, like, pleats in a wrinkled shirt. It's a result of things getting thin and wrinkly, and if we thicken that up, a lot of those lines can improve. Downtime with a fractionated ablative laser is typically limited to redness and swelling, and kind of like with the full-field lasers, the deeper and more aggressive we are, the longer that redness and swelling is going to last. Typically for most of our treatments, you can figure between three to five days of noticeable redness and swelling, and most of that you can wear makeup—for the ladies—to cover that.
On the other hand, the second category of ablative lasers are full-field lasers, and these are good for much more severe lines and wrinkles, and severe textural or pigment problems. A full-field laser is exactly what it sounds like. It treats the entire surface of the skin during a course of a treatment. If we're sticking with our landscape analogies, this is like mowing your lawn. And the more aggressive we get with our full-field ablative laser, the lower and lower and lower and lower we make the deck of our lawn more to the ground.
With light or superficial treatments, that's like, kind of, taking the tops off the grass; with very deep or aggressive treatments, it's the equivalent of taking it down to the dirt, and then laying sod down on top of that. And we can adjust our treatments anywhere in between. Typically, that adjustment comes with a discussion between you and me of what we're looking to treat, how aggressive you want to be, but then how much downtime you want to deal with after that treatment. If we're doing superficial treatments, you can guess maybe a day of just some light peeling, maybe some pinkness, if we're going down deep kind of where we're laying sod down, that's four or five days you're not going to want to leave the house. The recovery is pretty intense. And so we have to talk about where you are on the spectrum of results in recovery to figure out which ablative full-field treatment is right for you.
Lasers are really an integral part of cosmetic medicine and surgery, but kind of like with skincare, it gets really confusing really fast, if you don't start out and really understand what you're treating, and then you compound that by not really understanding what the treatments are. And so a lot of people spend a lot of money on treatments that really aren't right for them because neither they nor their aesthetic medicine provider has taken the time to make an accurate diagnosis and then recommended an accurate treatment plan.
To go over again what we talked about today, there are two main categories of lasers: There are non-ablative lasers—and in that we include IPL or BBL—and there are ablative lasers. Non-ablative lasers are really good in treating things like red pigment and blood vessels, brown pigments, they're at good maintenance treatment for skin aging, they are good treatments in conjunction with topical and oral treatments for acne, and they do a very good job at laser hair removal.
On the other hand, ablative laser treatments come in two different varieties. You have your fractional ablative lasers and fractional ablative lasers are really good for mild to moderate skin wrinkling, they are used to rejuvenate and thicken thinning skin, and they are used to help remodel and improve surgical scars, trauma scars, and acne scars. Full field ablative lasers really shine when it comes to making significant and dramatic improvements in surface texture. An added benefit to that is that it will treat pigment at the same time. And we can dial in the depth of treatment, the downtime, and the results based on your individual preferences.
I tell my own patients that we can either take the scenic route, or we can take the highway. We get to the same destination, it just depends on how long we take to get there. If we choose an ablative laser—whether that's a fractional or full-field—we choose a treatment with minimal downtime, it's going to take us a number of extra treatments to get to our same result—we're on the scenic route—as opposed to being aggressive and needing one treatment or maybe two treatments to get to that same endpoint, but your downtime is much more significant.
One of the things that I hear people complain about is that they've had a laser treatment somewhere that didn't work. My first question is, “What treatment did you have?” Because oftentimes, it will be somebody looking for wrinkle reduction or an anti-aging treatment who has had a non-ablative laser treatment. And right there I say, “Well, that's probably the reason is that the treatment just wasn't powerful enough to accomplish your goals.” If they've had an ablative laser treatment, that's when I really would like to know what was used and what was done because oftentimes, it's a matter of patients and their laser provider not having a detailed discussion about results and downtime because a lot of patients see laser as being this magic treatment with no downtime, and that just isn't the truth.
And as a result, these patients show up, they'll have an ablative fractional laser treatment and it won't have been very deep, they didn't have much downtime, and then they are upset because they didn't get much of a result. And in those cases, that's when we have this discussion about the scenic route versus the superhighway. You can have the treatment with minimal downtime, but it's going to take a lot of those treatments to get to the same endpoint. So, just take that with you, understand that there's a lot to discuss when you start talking about laser treatments, there's a lot of questions to ask, and I hope this show really helped to provide you with some background to be able to ask those questions so that you're getting a treatment that is going to accomplish your goals with the downtime that you're looking for, and in a manner that really suits both your timeframe and your budget.
I appreciate you taking the time to listen to this, kind of, science-y background, nerdy laser part, but I hope it helps you to understand the different types of treatments that are out there, and why certain treatments may not work for certain patients. So, thank you a bunch. I appreciate you listening. As always, give us five stars if you liked it, and subscribe on whatever platform you like enjoying podcasts. Thanks.
Dr. Hall: Thanks for listening to The Trillium Show. You can keep up with the latest on the podcast at jhallmd.com. Be sure to follow us on Spotify, Apple Podcasts, or wherever you listen to podcasts. If you want to connect with us on social media, you can find us at @jhallmd on Instagram and Twitter and @DrHallPlasticSurgery on Facebook. Remember, be the change you wish to see in the world.