A High-Tech Weapon in the Fight Against
Normally this is not a good thing where humans are
concerned. In science fiction films the characters vaporized by
a laser simply disappear. Patients opting for cosmetic laser
surgery, however, suffer a less severe fate: Only their
wrinkles and other skin imperfections disappear.
In recent years, lasers have shed their science fictional
image to become a surgeon's and dermatologist's most promising
weapon in the fight against aging skin. According to the
American Academy of Cosmetic Surgery in Chicago, nearly 170,000
Americans, men and women, underwent laser resurfacing of the
face in 1998, up from 138,891 in 1996--a 64 percent increase.
That's nearly twice the number of the more traditional surgical
facelifts performed in the same year.
Laser resurfacing is a very controlled burning procedure
during which a laser vaporizes superficial layers of facial
skin, removing not only wrinkles and lines caused by sun damage
and facial expressions, but also acne scars, some folds and
creases around the nose and mouth, and even precancerous and
benign superficial growths. In a sense, the laser procedure
creates a fresh surface over which new skin can grow.
While the Food and Drug Administration does not regulate how
surgeons carry out these procedures, it is responsible for
clearing lasers for marketing for the uses requested by the
Lasers in Cosmetic Surgery
Since their 1958 discovery, lasers have become a powerful
industrial tool, but their applications in medicine have been
truly revolutionary. One reason, says Richard Felten, a senior
reviewer in FDA's Center for Devices and Radiological Health,
is that lasers used as surgical tools can cut through tissue
without causing excessive bleeding. In fact, lasers actually
can coagulate tissue to stop bleeding. "That's something a
knife can't do," Felten says. Also, for many internal
procedures, surgeons can get the laser's energy to reach areas
within the body more easily than with a scalpel. And finally,
the wavelengths of the laser light itself lets surgeons use the
device selectively on very specific types of tissues, such as
port wine stains or hair follicles, without affecting nearby
"Other Laser Treatments")
But using lasers for facial skin resurfacing was discovered
almost by accident, Felten says. In the course of treating acne
scars with a laser, surgeons noticed that after resurfacing the
skin around the scar to make the scar less visible, small
adjacent wrinkles were greatly diminished.
"Resurfacing is very appealing to people," says Stephen W.
Perkins, M.D., president of the American Academy of Facial
Plastic and Reconstructive Surgery and of the Meridian Plastic
Surgery Center of Indianapolis, Ind., "because it is a way of
refreshing the skin's surface and getting a new layer of
non-sun damaged and more youthful skin."
Collagen is a key fibrous protein in the skin's connective
tissue, and it helps give the skin its texture. Natural aging
and such factors as sun damage and smoking help break down the
collagen layer so that the skin's once smooth surface develops
wrinkles. New, more youthful collagen actually forms after
laser treatment, says A. Jay Burns, M.D., partner in the Dallas
Plastic Surgery Institute and assistant professor of plastic
surgery at the University of Texas Southwestern Medical
Laser resurfacing can often make patients look 10 to 20
years younger, and the results can last for eight to 10 years,
says Tina Alster, M.D., director of the Washington Institute of
Dermatologic Laser Surgery in the nation's capital. But she
warns that after surgery, patients must avoid sunbathing and
destroying their skin again. Patients can have a repeat
treatment after one year, but usually the first procedure is so
successful a follow-up is not needed.
Lasers cannot rejuvenate skin on other parts of the body nor
can laser treatment lift or remove sagging jowls or smooth out
"crepey" or sagging neck skin. These conditions only respond to
traditional cut-and-stitch surgical methods.
Is Resurfacing for You?
Not everyone makes an ideal candidate for laser resurfacing,
Perkins explains. "Certain people with very sensitive skin
cannot tolerate the medications and lubricants used on the skin
during healing." Perkins also feels that the darker-skinned
ethnic groups are not candidates because the laser treatment
alters the color of skin too dramatically and unpredictably.
Alster, on the other hand, believes that in the hands of a very
experienced surgeon, people with darker skin tones, although
not ideal candidates, can benefit from surgery.
Alster warns that anyone not mentally prepared for
resurfacing or who expects instant results is not a good
candidate. "This is not easy in-easy out surgery," she says.
"Potential patients have to realize that there will be bruising
and swelling and they will be holed up in the house for seven
to 10 days," she says. "They will have a crusty, oozy, bruised,
scabbed, raw-appearing face." Further, they should not expect
unflawed skin. "I can't deliver that," she says. "I am not able
to give unlined, unscarred skin." Patients, however, can expect
a 50 percent or greater improvement.
They must also plan on at least 10 days of healing before
applying any makeup. For satisfactory healing, that means
following rigorous after-care treatment, including proper skin
cleansing, the application of a skin lubricant, and the
frequent changing of dressings.
What Are the Risks?
As with any medical procedure, patients may experience
certain complications--most temporary--including a prolonged
redness of skin, tenderness, easy flushing, and some pigmentary
changes, like hyperpigmentation, when the skin appears darker
than normal, says Rox Anderson, M.D., director of the Laser
Center at Massachusetts General Hospital in Boston.
Other risks are more serious, and possibly permanent,
including hypopigmentation, or lightening of the skin.
"Somewhere between one to two years after treatment it becomes
clear that there is a permanent lightening of the skin color
where the resurfacing was done," he says.
And scarring may occur in about 2 percent of the cases, he
adds, from poor postoperative care, during which time an
infection may develop. Or a surgeon may go too deep during the
procedure, creating an injury the skin cannot repair, says
Consider the case of Anne Jones (not her real name) in
semi-rural Mississippi, a stay-at-home mom and a doctor's wife.
Wanting to remove some mild acne scars, she went to a
well-respected local plastic surgeon, but after a five-month
recovery period, Jones realized that something had gone very
wrong. "He had just burned my face," she says. It was red, with
scar tissue all over, she adds.
Eventually, Jones went for help to an ophthalmologist who
had extensive laser knowledge--many ophthalmologists use lasers
for corrective eye surgery. He took one look at her and
exclaimed, "Oh, I am so sorry this has happened to you." He
told her that the surgeon had been too aggressive and had not
used the right settings, so that her skin had retained too much
heat and had been severely burned.
Because both qualified and unqualified practitioners are
flooding the cosmetic laser surgery field, consumers may face
some real hazards. "All of a sudden, there's widespread use of
lasers by unqualified people," says Perkins, who notes that
some laser manufacturers are so eager to sell their products
that they stage one- or two-day meetings, or courses, for
training. That means that even dentists, obstetricians,
gynecologists, and family doctors are now offering laser
surgery, says Alster.
"The person planning to do laser surgery must understand the
basic physics of how laser energy is absorbed by tissue and how
tissue responds," warns FDA's Felten. "Then that person should
go where the surgery is performed and watch a skilled surgeon
use the equipment." Besides that, says Anderson, the best
people to work with lasers on skin conditions are the
professionals who best understand skin and surgery of the skin:
dermatologists and plastic surgeons.
"Sometimes people may choose the wrong laser, or a surgeon
may believe more is better, which can lead to significant
burning," says Alster. And some operators don't know they must
keep wiping off the partially desiccated skin or that they must
keep moving the hand holding the laser instrument during the
To date, no national policy exists for credentialing those
planning to practice laser surgery. Felten says FDA is
responsible for granting individual manufacturers permission to
market their lasers for the specific indications requested. FDA
also often recommends training needed to operate the
But credentialing is a state function, since states are
responsible for the licensing of doctors and nurses, and
standards for laser training vary from state to state.
That's bad news for patients like Jones. Two years have
passed since her procedure and she has spent nearly $70,000 for
both the initial surgery and subsequent consultations and
corrective surgeries to remove the scarring. She says she has
partially reclaimed her life. But she bitterly regrets
undergoing the initial surgery. "I will never look right," says
Jones. "I would never do this again."
Finding the Best Surgeon
Selecting a laser surgeon is just like picking a qualified
doctor for any medical treatment. "Consumers ask more questions
of auto mechanics," says Alster. "This is surgery and with it
comes inherent risks and complications. While it is perceived
as easy, it is not. When you are talking about skin, it is
harder to treat than eyes."
The Internet is a good place to start the search. Consumers
can find thousands of Websites, including those for
specialists, laser and plastic surgery societies, and
information pages. But consumers should be wary of assuming the
accuracy of any information taken off the Internet because the
unscrupulous can put up their own Web pages just as easily as
can the qualified.
Alster suggests interviewing several doctors and evaluating
their answers and their credentials. After all, she adds, it's
the doctor's skill that counts--the laser is just the doctor's
The next step is crucial: asking the right questions. Alster
advises asking where the doctor has trained and if he or she
owns or rents the equipment--those who own have likely made a
commitment to training and to laser surgery. Ask to see before
and after pictures of the doctor's cases, and find out how many
different types of lasers the doctor owns and how often each
piece of equipment is used. "There is not one laser that does
everything," she says, cautioning patients to select a surgeon
whose practice offers more than one laser system. "One needs to
use [the right] laser for the right lesion. So the person
examining you must make the correct diagnosis," she says.
Alster herself has at least 10 different lasers in her
Of course, the final decision may be difficult, since no
doctor can guarantee perfection or complete safety, but
well-informed patients with reasonable expectations may be one
step closer to younger, fresher-looking
Consumers needing information
about cosmetic laser surgery or about how to select a qualified
practitioner can contact these associations:
American Academy of Cosmetic Surgery
401 N. Michigan Ave.
Chicago, IL 60611
1-800-A New You (1-800-263-9968)
American Academy of Dermatology
930 N. Meacham Road
Schaumburg, IL 60173
American Academy of Facial Plastic and Reconstructive
310 S. Henry St.
Alexandria, VA 22314
American Society for Aesthetic Plastic Surgery
American Society for Laser Medicine and Surgery Inc.
2404 Stewart Square
Wausau, WI 54401
American Society of Plastic Surgeons
444 E. Algonquin Road
Arlington Heights, IL 60005
1-888-4 PLASTIC (1-888-475-2784)
Article above by Alexandra Greeley