Laser zaps wrinkles, boosts caseloads
Laser zaps wrinkles, boosts caseloads
Laser gives high precision, good results
Thanks to media attention and word-of-mouth from satisfied patients, laser resurfacing with a CO2 high-energy, quick-pulse laser has become the "hot" new plastic surgery procedure, attracting patients who would not consider undergoing a chemical peel, dermabrasion, or facelift, plastic surgery experts say.
"It's an amazing part of our practice," says W. Earle Matory Jr., MD, FACS, director of 'A New You' plastic surgery group in Irvine, CA, who has been performing laser resurfacing for about a year and has seen "dramatic growth" in patients asking for the procedure.
The new high-energy lasers effectively reduce or remove wrinkles, age spots, stretch marks, and scars with great precision, rapid recovery, and minimal patient discomfort, says Matory. The procedure is comparable to a highly effective chemical peel, plastic surgery experts say.
Most patients reepithelialize three to five days after a laser resurfacing, as opposed to a healing period of 10 days to two weeks with the traditional phenol chemical peel, says William Beeson, MD, clinical assistant professor in the departments of dermatology and otolaryngology at Indiana University School of Medicine in Indianapolis. Some physicians report longer healing times more similar to chemical peels or dermabrasion, but tout the precision of the technology.
Although the new lasers are expensive -- about $100,000 plus annual maintenance fees of $5,000 or more -- the new patient volume and their varied uses makes them worth the expense, says Beeson, a consultant to Sharplan Lasers of Allendale, NJ. "In this day and age, people like the high tech and high touch," he says. "Many patients don't even want to think about having a chemical peel. They favor the laser."
Beeson also uses the laser for facelifts, blepharoplasty, hair transplantation, and removal of skin cancer lesions. "The CO2 laser opens up a whole new vista for facial plastic surgery," he says.
The new CO2 lasers use very short bursts of high energy to vaporize tissue. The result: very little residual tissue damage.
"It essentially peels off the skin bloodlessly," says A. Jay Burns, MD, FACS, assistant professor of plastic surgery at the University of Texas-Southwestern Medical School in Dallas.
"Each pulse of the laser is of such high energy that it has to effect the skin for a very short period of time, less than a millisecond," says Burns. "The amount of residual char is so small, it's measured in microns. It's practically nil."
The heat that is transferred to surrounding tissue causes collagen to shrink an estimated 20% to 40%, Burns says. In other words, in addition to removing the top layer of skin for resurfacing, the laser treatment tightens the remaining skin, he says.
"It's kind of like the ultimate deep facial," Burns says.
Creams, IVs minimize discomfort
The patient has minimal discomfort during the laser abrasion, says Beeson. He uses EMLA cream to numb the area about two hours before the procedure. Matory favors an injection of lidocaine. When doing a full face resurfacing, which includes sensitive areas around the eyes, Burns uses IV sedation. This has to be handled cautiously, however, because oxygen cannot be used near a CO2 laser because of fire hazards, Burns says. After the sedation, he uses nerve blocks.
With deeper rhytids (wrinkles), Beeson notes better results with two or three laser abrasions at three-month intervals. The laser also can be used in conjunction with traditional dermabrasion to treat deep scars, he says.
Although laser resurfacing carries low risk, there are several possible side effects. Hyperpigmentation, or prolonged pinkness of the skin, can occur in about 20% of patients and lasts for two to six months before going away on its own, says Burns. Hypopigmentation, or lightening of the skin, occurs less frequently. Burns also says that 15% of his patients develop milia, or white heads, which can be treated with Retin A and removed.
Laser resurfacing is most successful with fairer skin tones; those with dark brown or black skin types are not good candidates for the procedure, Burns advises.
Matory treats unwanted skin discoloration with kojic acid, glycolic acid, or hydroquinone, or a combination of the three. Scarring or burning or the skin may occur if the procedure is not done properly, he says.
The laser also presents a risk to eyes and teeth. Burns recommends that an OR nurse be designated a laser safety officer to check that all personnel in the OR are wearing appropriate protective eyewear. Patients' eyes are protected by a laser eye shield, and teeth can be protected with moist cotton, he says.
Although Burns has not personally had any patients who experienced scarring, he notes that scarring is a possible complication if the laser abrasion goes too deeply into the dermis.
Despite these cautionary notes, overall the procedure has produced excellent results, plastic surgery experts say.1 Because laser resurfacing is new, (the CO2 lasers have become available in the past two years) its long-term record is still unclear. Burns is following patients postoperatively at one day, three days, 10 days, six weeks, three months, six months, one year, and every year after that.
"We don't know how long it's going to last," he says. "That's the major downside. No one knows, because it hasn't been around that long."
It may be great, but can you afford one?
Deciding whether to buy a CO2 high-energy pulse laser may be difficult because of the cost. The lasers, manufactured by Sharplan and Coherent, range in cost from $70,000 to $130,000.
Physicians are charging $2,000 to $6,000 for a laser resurfacing, compared to $1,000 for a chemical peel, Burns says. Same-day surgery centers that own the lasers charge a facility fee of $500 to $700 per case for a full face resurfacing, which takes about an hour to an hour and a half, he says.
Beeson didn't raise his fees when he purchased the laser. He charges the same for a laser resurfacing as for a chemical peel or dermabrasion. "I use the laser because I feel I can get better results, quicker healing, and more patient satisfaction," he says. "I'm looking at the ultimate product."
Having a CO2 high energy pulse laser also has increased his case volume, he says. Beeson uses the laser for facelifts, blepharoplasties, and hair transplantation, which he says gives him greater precision, virtually no bleeding, and better results.2
The laser has other benefits, as well. Research has shown that early squamous cell carcinoma in situ can be removed by the laser with no recurrence after two years. Instead of sending a part of a lesion for biopsy, then asking patients to return for a laser removal, Beeson simply removes suspected cancerous lesions.
"I can save [patients] the biopsy cost," he says. "It allows me to treat lesions more quickly and much more cost-effectively."
If the lesion recurred or didn't heal properly, Beeson says he would then excise it and have it biopsied.
Because of the high cost, not every physician will be able to afford to buy the CO2 lasers, Beeson notes. That overhead burden for physicians presents an opportunity for same-day surgery centers, he says. "It may allow them to capture a larger percentage of elective facial surgery," he says.
Matory agrees that the lasers present a significant opportunity for same-day surgery centers, but he advises same-day surgery managers to poll physicians and estimate how frequently the equipment would be used. They also should consider the competition, perhaps even hiring marketing consultants to assess the demand in the community, he cautions.
"The technology is sweeping the country so rapidly that you'll find laser centers on every corner," he says. "The question is whether there will be enough patients to pay for all lasers out there."
References
1. Olbricht SM. Use of the Carbon Dioxide Laser in Dermatologic Surgery: A Clinically Relevant Update for 1993. J Dermatol Surg Oncol 1993; 19:364-369.
2. Beeson WM, Kabaker S, and Keller GS. Carbon Dioxide Laser Blepharoplasty, a Comparison to Electrosurgery. International Journal of Aesthetic and Restorative Surgery 1994; 2:100000-4. *
For more information about the CO2 high-energy, quick-pulse laser, contact:
* William Beeson, MD, 8803 N. Meridian St., Suite 310, Indianapolis, IN 46260. Telephone: (317) 846-0846.
* A. Jay Burns, MD, Dallas Plastic Surgery Institute, 411 N. Washington, Suite 6000, Dallas, TX 5246. Telephone: (214) 823-1978.
For more information about the lasers, contact:
* Coherent (manufacturer of the Ultrapulse system), 3270 W. Bayshore Road, Palo Alto, CA 94303-0810. Telephone: (800) 227-1914.
* Sharplan Lasers (manufacturer of the Sharplan XJ- 150 Surgipulse and the Silktouch Flash Scanner), 1 Pearl Court, Allendale, NJ 07401. Telephone: (800) 394-2000.
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