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Lasers, Intense Pulse Light, and LED

Dr. Kenneth Rothaus understands the importance and use of cosmetic lasers, intense pulse light devices, plasma devices, and LEDs in an aesthetic practice. Dr. Rothaus knows that one aesthetic light device cannot be used for all problems and diagnoses. Therefore, he has amassed in his office a full line of aesthetic lasers, intense pulse light devices, LEDs and low level light lasers creating one of the most complete laser centers in a plastic surgeon's office in the New York City area and beyond.

The tools available to the aesthetic surgeon for rejuvenation of their patients include the use of light and plasma devices, as well as topical preparations. The light devices that are employed include:

1. Lasers
2. Intense Pulse Light Devices
3. Light Emitting Diodes
4. Low Level Light Lasers

When patients come to see Dr. Kenneth Rothaus, the most frequently asked questions regarding laser treatment are:

What is a laser and how is an intense pulse light device different?

The word LASER is itself an acronym for: Light Amplification by Stimulated Emission of Radiation. This just refers to the mechanics that happens inside the laser box to produce the laser light. The name of each type of laser refers to the element or substance in the box from which the light emanates.

Laser light has three unique characteristics:

1. It is monochromatic. This means that it includes only of one wavelengths of the electromagnetic spectrum.
2. It is coherent; that is, all the waves of light are in synchronization. They each reach their high and low points at the same time.
3. The light waves are collimated, or perfectly parallel, and never spread out.

Let us follow, for example, what happens in a carbon dioxide (C02) laser during a resurfacing procedure. When the laser is operating, a form of energy, which in this case is electricity, is used to excite the carbon dioxide in the tube. One of the "rules of physics" is that a substance will not normally remain in an excited state. When the carbon dioxide returns to its non-excited (resting) state, it gives off energy in the form of light. Inside the tube, there is a series of mirrors and filters that ensure that the light that comes out of the tube and the box meet the three previously described characteristics. The light is coherent, collimated and monochromatic.

1. Polychromatic (more than one wavelength)
2. Not collimated
3. Not coherent

Are LEDs and low-level light lasers different from lasers and intense pulse light devices?

An LED (light emitting diode) is a source of a low level light that is being used for a multitude of purposes (some of which are investigational), including reduction of inflammation, correction of hyperpigmentation, reduction in the appearance of spider veins and rosacea, improvement in texture and lines, reduction of wrinkles, acne control, and hair re-growth.

Low-level light lasers are lasers but of much lower energy and are being used for many of the same areas as described for LEDs, as well as for possible cellulite reduction.

Are they same safe? What are the risks?

The lasers and intense pulse light devices commonly used by the aesthetic laser surgeon operate in the non-ionizing electromagnetic spectrum and are quite safe when used properly. All lasers used for cosmetic procedures on the skin generally have the same risks. The most common include changes in the pigmentation of the skin (both lightening and darkening), blistering, and scarring. Fortunately, the incidence of these complications in hands of an experienced laser and plastic surgeon is small.

How does it work?

There are many different lasers and intense pulse light devices. Each laser, or intense pulse light device, can be used to treat a specific problem. The laser used to treat your wrinkles is probably not the best laser to treat your varicose veins. The laser light is absorbed by the skin, hair, blood vessel, tattoo, or whatever else is being treated. The energy in the laser light is converted to heat. The heat that is produced will alter, cauterize or ablate the target tissues.

This is similar to what happens to your car in the summer. The sunlight is absorbed by the car's seats, and they become hot. Similarly, the laser light is absorbed by the tissues and is converted into heat. It is this heat that results in the final action. For example, when a laser is used to treat spider veins, the laser surgeon will choose a laser that is absorbed by hemoglobin, a substance found in all red blood cells. The heat produced will then damage the blood vessels so that they constrict.

What are the layers of the skin?

The skin is composed of two layers. The more superficial is called the epidermis and the deeper the dermis. The dermis is composed of the deeper reticular dermis and the more superficial papillary dermis. Laser surgeons refer to the border between the dermis and epidermis as the DE junction. Similarly, the border between the two layers of the dermis is referred to as the papillary reticular junction.

What is the Fitzpatrick Classification?

The Fitzpatrick Classification divides skin types into 6 categories based upon their reaction to the sun. A Fitzpatrick I skin type is a fair skin, fair haired, blue eye person who always burns and never tans when exposed to the sun. A Fitzpatrick VI patient, on the other hand, has dark skin and never burns. Fitzpatrick II - rarely tans, usually burns; Fitzpatrick III - usually tans, sometimes burns; Fitzpatrick IV - usually tans, rarely burns; and Fitzpatrick V - always tans, very rarely burns.

What is non-ablative resurfacing?

Non-ablative resurfacing refers to the treatment of skin, usually of the face, where the overlying epidermis is left intact. Treatment of pigment, collagen, vessels and even fat below the epidermis is referred to as non-ablative resurfacing.

What is ablative resurfacing?

In ablative resurfacing, the epidermis is removed and exposes the underlying dermis. This creates a wound that the body has to heal in order to restore the epidermal layer.

What is fractional resurfacing?

Fractional resurfacing is a process in which the epidermis, dermis, entire thickness of the skin, or the subcutaneous tissues are "lasered," creating dots or columns of treated tissue surrounded by tissue which has not been treated. This polka dot pattern of treatment allows the treatment depth to go deeper because the laser wound is healed rapidly due to the surrounding "normal" tissue.

Fractional resurfacing can be either ablative or non-ablative. It can be used for wrinkle reduction, treatment of pigmentation and texture, and skin tightening.

What is a plasma skin resurfacing?

Plasma skin resurfacing is a new technology that does not use light, it instead harnesses similar energy found in the sun to improve the texture and pigmentation of the skin, reduce wrinkles and tighten the skin. Plasma is the fourth state of matter (in addition to solid, liquid and gas) and represents a superheated version of gas. For the Portrait device, the gas is nitrogen. Plasma skin resurfacing is considered a non-ablative form of resurfacing because the epidermis is left intact after the procedure, acts as a protective biological dressing as new epidermis is formed, and gently flakes off after a period of 4 to 7 days.

Lasers, Intense Pulse Light, Light Emitting Diodes and Plasma

The lasers, intense pulse light devices, LED, and plasma devices currently in the practice include the:

• StarLux 300 and 500
• Gemini
• Aura
• EpiTouch
• CoolTouch III
• CoolTouch Endovenous
• CoolLipo
• Venus
• Medlite IV
• Portrait
• GentleWaves Yellow and Red panel
• SmoothShapes
• UltraPulse Encore
• Slim Lipo

The StarLux 300 and 500 incorporate a vast array of laser and intense pulse light hand pieces. The hand pieces for these two aesthetic light devices that are currently in our practice include the:

• Lux 1540
• Lux 2940
• Lux IR
• Lux Deep IR
• Lux Y
• Lux G
• Lux R
• Lux Rs
• Lux V
• Lux 1064

The aesthetic procedure that can be performed with these devices include:

• Skin Resurfacing
• Ablative
• Non-Ablative
• Fractional
• NonFractional
• Reduction of Hyperpigmentation (brown spots)
• Correction of Vascular Abnormalities
• Skin Tightening
• Amelioration in the Appearance of Wrinkles and Scars
• Hair Reduction
• Treatment of Spider Veins and Varicose Veins
• Laser Lipolysis (Liposuction)

Starlux Series of Lasers

Base Units: StarLux 300 and StarLux 500

The StarLux 300 and 500 represent a technology in which a laser or intense pulse light device can be built upon a single base platform by adding individual hand pieces. The 500 is the newest of the base units to be released by Palomar Medical Technologies. Its upgrades include a more powerful cooling unit that enables the addition of newer hand pieces, such as the Lux 2940 (an erbium laser for fractional resurfacing) and upgrades to existing hand pieces that can operate at faster speeds.

StarLux Hand pieces

Intense Pulse Light Hand pieces and Their Applications in My Practice:

• Lux Y – hair removal (predominantly in patients with Fitzpatrick I, II, III and IV skin types)
• Lux R – hair removal in all skin types
• Lux Rs - hair removal in all skin types
• Lux G – hyperpigmentation, facial vessels including rosacea, rejuvenation of face, neck and chest skin
• Lux V – hyperpigmentation and acne treatments
• Lux IR - skin tightening
• Lux Deep IR - skin tightening

Laser Hand pieces

• Lux 1064 – treatment of leg spider veins and varicose veins
• Lux 1540 – hyperpigmentation, facial rejuvenation (improvement of skin texture), and scar revision. This is a non-ablative fractional resurfacing hand piece
• Lux 2940 - facial rejuvenation and resurfacing scar revision; this is an ablative fractional resurfacing hand piece which is used for wrinkle reduction

Gemini Laser, Aura Laser, Lyra Laser

The Gemini, Aura and Lyra lasers are a family of lasers that are now sold and manufactured by Iridex, which purchased the aesthetic division of the original manufacturer (Laserscope). The Aura and Lyra are single wavelength lasers. The Gemini incorporates the wavelengths of both the Aura and Lyra lasers and operates at a much higher power than the Aura laser for the green light side of its output.

Aura

The Aura laser is a KTP laser, which operates at 532 nm.

It has many aesthetic uses as it targets both the hemoglobin in blood and the melanin (pigment) in skin and hair. The Aura laser can be used for the treatment of small spider veins of the face and leg, including those found with rosacea, cherry angiomas (spots) of the entire body, and hyperpigmentation of the skin (brown spots). It is also employed to aid in non-ablative facial rejuvenation. Non-ablative facial rejuvenation is the process that is often referred to in the lay press as the "lunchtime laser peel or facial." The Aura has also been approved for treatment of acne.

Lyra

The Lyra laser is a long pulse width laser (ND:Yag), which operates at 1064 nm. It can be used for 3 different treatments! These treatments are hair removal, the ablation of varicose veins and spider veins, and non-ablative facial resurfacing:

• The Lyra laser is approved for hair removal in all patients regardless of their skin color.
• It can effectively treat spider veins and varicose veins up to 4 mm in diameter.
• The Lyra is used in conjunction with the Aura laser for non-ablative facial rejuvenation.

Gemini Laser

The Gemini laser was the newest of the aesthetic lasers developed by Laserscope prior to its sale. It incorporates both the 532 and 1064 wavelengths of the Aura and Lyra lasers; however, the 532 (also known as KTP or green light) portion is much more powerful than that found in the Aura. This makes it possible to deliver higher fluences and deliver larger spots for treatment of facial capillaries and rosacea. The 1064 side of the Gemini laser is unchanged from the Lyra.

Thus, the Gemini laser can be used to treat all facial pigmentation – capillaries, brown spots, hyperpigmentation, melasma, rosacea, acne, spider and varicose veins of the leg, facial rejuvenation, and for hair removal.

CoolTouch III©

The CoolTouch III© laser is a 1320 nm ND:Yag laser. It can effectively eliminate or soften wrinkles and acne scars. It is being investigated to treat stretch marks as well. There is no "down-time" for the patients treated with the CoolTouch ©; therefore, it also is one of the lasers used for non-ablative facial resurfacing or rejuvenation. Our CoolTouch III laser has the upgrade that enables it to also be used for endovenous treatment of large varicose veins.

Med-lite IV

The Medlite IV laser is another type of ND:YAG laser that operates at 532 and 1064 nm as the Gemini. Unlike the Gemini, which operated at longer pulsewidths measured in milliseconds, the Med-Lite IV is a Q-switched laser. Q-switched lasers operate at very short pulse-widths, nanoseconds. This difference in pulse widths results in a different mechanism of ablation of the target. The mechanism of ablation with q-switched lasers is known as photacoustic. It is almost as if a "mini-sonic boom" disrupts the target mechanically. In contrast, the mechanism of ablation with lasers that operate over longer pulsewidths is photothermal. This means that the target is ablated by heat that is generated by the light which is absorbed.

The Med-lite IV can be used with a variety of hand pieces, which enable it to produce laser light at 585 nm and 650 nm in addition to the 532 nm and 1064nm. This laser is very versatile and can be used for many purposes, including the removal of brown spots and tattoos of many colors, the improvement of hypertrophic scarring, and, in some cases, the treatment of unwanted hair, skin blemishes, vessels, and textural changes.

Epitouch (Alexandrite)

The Alexandrite laser is a 755 nm laser. It is also for hair removal in many, but not all, skin types.

Venus Laser

The Venus laser, which was originally manufactured by Laserscope and is now a product of Iridex, is an erbium laser used for skin rejuvenation. The erbium, or 2940 wavelength, is highly absorbed by water and, results in ablation or removal of very thin layers of skin with each pass. The laser surgeon is able to limit the removal of skin to the epidermis or very superficial dermis. This results in a more rapid healing when compared to more aggressive resurfacing lasers such as the CO2 laser.

For many lasers, the depth of treatment within each spot is not uniform and is deeper in the center than at the periphery. This results in an uneven ablation. The Venus has a "top hat" waveform, which means that the degree of ablation is uniform throughout. For this reason, the Venus laser is very well suited for light peels, or so-called overnight or weekend laser peels.

SmartLipo and CoolLipo

The SmartLipo and CoolLipo are two lasers developed by Palomar and New Star lasers, respectively. The laser light is passed under the surface of the skin and has been reported to accomplish two tasks:

• lipolysis or ablation of fat cells
• modulation of the skin resulting in remodeling and tightening

The patients still require some conventional suctioning after the treatment with the lasers, but are stated to note less discomfort and post-treatment bruising as well. In addition, this procedure is able to be performed under a local anesthesia and often does not require wearing a compression garment as required with conventional liposuction.

Ultra Pulse Encore

This CO2 laser manufactured by Lumenis incorporates many different technologies for the delivery of CO2 laser light:

• Ablative
• superficial fractional
• deep fractional
• surgical cutting
• The manufacturer refers to these various modalities as:
• Pigment Fx
• Active Fx
• Deep Fx
• Total Fx

These are used for the correction of pigmentation (dyschromia or brown spots), superficial and deep wrinkles, dermal lesions, and collagen remodeling (skin tightening).

SmoothShapes

SmoothShapes is a low-level light laser device that incorporates the use of light operating at 915 nm and 650 nm, as well as compression and roller devices to improve the appearance of cellulite. It has been approved by the FDA for that purpose and, according to the manufacturer, has been shown to demonstrate a "significant volumetric reduction in subcutaneous fat" in 81% of participants in a clinical study.

GentleWaves

The GentleWaves is an LED (light emitting diode) that incorporates both yellow and red panels. The yellow panel has been shown to reduce inflammation, increase collagen, ameliorate the appearance of wrinkles, reduce fine vessels (red pigmentation), and reduce hyperpigmentation (brown pigmentation). The yellow panel LED is incorporated in my practice in every laser treatment, as well as being used as a stand-alone series of treatments by itself or in conjunction with other treatments such as microdermabrasion and glycolic peels.

The red panel is currently under investigation for the treatment of acne, as well as reversal of hair loss in the balding scalp.

Plasma Skin Resurfacing

Portrait

The Portrait is a plasma skin resurfacing device that uses heat directly without the application of a laser or intense pulse light device to resurface the skin. As previously described, nitrogen plasma (a superheated, ionized version of nitrogen gas) is directed onto the skin through a hand piece. The energy in the nitrogen plasma is liberated upon contact with the skin and nitrogen gas is harmlessly released into the atmosphere. The depth of penetration of the heat is dependent on the energy selected by the laser surgeon – the higher the energy, the deeper the depth of treatment. Regardless of the energy chosen, the epidermis remains intact, thus, no open wound is created.

The patients can be treated on the face, neck, chest, arms, and hands. There are 3 different treatment protocols. The high-energy treatment protocol can only be used on the face. The patients are treated using only a topical anesthetic. The overlying epidermis becomes light brown or bronze in color and will peel off after 4-7 days. The patients can expect improvement in the pigmentation of their skin, the appearance of the texture and wrinkles, and over a course of 6-12 months, some tightening of the skin, especially around the eyes.

The "medium treatment" involves a series of 3 treatments over a two month period. A lighter energy is used and, as a result, it has a shorter "downtime" by several days and can be used on all the areas described above - face, neck, chest, arms, and hands.

The "plasma express" treatment is a very light treatment that requires multiple treatments, but has little to no downtime.

In our experience, the Portrait and plasma skin resurfacing technology result in a significant improvement in the appearance of the patients skin on and off the face and competes very satisfactorily with other resurfacing technologies. Also, one additional unique aspect about Plasma is how it can be used around the upper and lower eyelids, achieving significant skin tightening.

Procedures

Wrinkle Reduction

The following lasers, intense pulse light devices, light emitting diodes, and plasma devices are all used in my practice for wrinkle reduction:

Lux 2940 — fractionally ablative erbium laser
UltraPulse Encore — fractionally ablative CO2 laser
Portrait — non-ablative plasma resurfacing device
Venus — ablative erbium laser
CoolTouch III — non-ablative laser
GentleWaves — LED

Skin Tightening

The lasers, intense pulse light devices, and plasma devices that may be used for skin tightening are:

LuxIR and DeepIR — Intense Pulse Light
Portrait — Plasma
UltraPulse Encore — CO2

Correction of Hyperpigmentation (Brown Pigment)

The lasers, intense pulse light devices, LEDs, and plasma devices used for correction of hyperpigmentation in my practice are:

LuxG — Intense Pulse Light
Gemini — Laser
Aura — Laser
MedliteIV — Laser
Portrait — Plasma
Lux1540 — Laser
UltraPulse Encore — Laser
GentleWaves — LED

Correction of Rosacea, Spider Veins, and Other Vascular Facial Lesions

Gemini — Laser
Lux G — IPL
Aura — Laser
Medlite IV — Laser
Gentlewaves — LED

Correction of Surgical, Traumatic and Acne Scars

Lux 1540 — Laser
Lux 2940 — Laser
Medlite IV — Laser
Lumenis Encore — Laser
Venus — Laser
CoolTouch III

Other Laser Procedures

Laser Lipolysis

CoolLipo — Laser
Slim-Lipo-Laser

Correction of Tattoos

Medlite IV — Laser
Lux 1540 — Laser

Correction of Spider Veins and Varicose Veins

Gemini — Laser
Lux1064 — Laser
CoolTouch Endovenous — Laser

Hair Removal

Lux Y — Intense Pulse Light
Lux R — Intense Pulse Light
Lux Rs — Intense Pulse Light
Gemini — Laser
Alexandrite — Laser
Medlite IV — Laser

Cellulite

SmoothShapes — currently under investigation

For additional information on Aesthetic Procedures, go to www.rothausmd.com