Laser Rejuvenation

Background:

The Dermatology & Laser Center has been using lasers to improve the skin since 1989. Over this time period, we have used many different lasers to help reduce wrinkles, improve brown spots and improve unwanted redness. We currently have a collection of state-of-the-art lasers and radiofrequency devices to safely improve the look and feel of the skin.

In other sections we have described the eMatrix device with which we perform the Sublative™ procedure, the eTwo™ that we perform the Sublime™ procedure, and the ePrime™ with which we perform the Evolastin™ procedure.

The two main lasers we now use for skin rejuvenation are the Candela VBeam Perfecta™ laser and the Syneron/Candela CO2RE™ fractional CO2 laser.

First we will describe the VBeam Perfecta™ and how it may be used to rejuvenate the skin.

Applications:

• Fine wrinkles
• Unwanted brown spots
• Unwanted red spots

This laser is what is called a pulsed dye laser and has primarily been used to treat blood vessel disorders. It was found to be effective in reducing fine to moderate wrinkles in a way that does not affect the surface. There is essentially no downtime associated with this procedure. We usually do four treatments, one month apart. These treatments only take ten minutes. We often recommend one maintenance treatment every six months.

Example of treating fine wrinkles around the eyes:















Another example of treating fine wrinkles around the eyes:
















This is an example of treating brown spots on the face:
















Now we will describe the CO2RE™ fractional CO2 laser for treating more surface sun damage and mild to moderate wrinkles.

Applications:

• Skin resurfacing
• Wrinkle and scar reduction
• Fractional ablative treatments

Variable Treatment Modes:

The CO2RE system provides a total of seven different treatment modes including four fractional ablative treatment modes and pattern shapes.





































By delivering both surface and deep pulses at the same time, we may easily treat moderate sun damage, including brown spots and wrinkles.

This is an example of one of our patients with mild to moderate wrinkles and sun damage:

















This is another example of one of our patients with moderate wrinkles:

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What is a vascular laser?

Vascular lasers are those lasers that are able to remove or treat a wide variety of abnormal blood vessel growths.

What are the types of vascular lasers?

In our office we have Candela's Vbeam Perfecta pulsed dye laser, Candela's GentleLase Plus alexandrite laser, and Candela's GentleYAG Nd:YAG laser for use in treating abnormal blood vessels.

There are pros and cons to each laser but we have chosen our lasers for specific reasons. The Candela pulsed dye laser was the original laser used to treat vascular abnormalities, especially those in children. Since our first pulsed dye laser in 1989, there have been many improvements leading to the Vbeam Perfecta laser.

The Candela GentleLase, although first used for hair removal, has become a very useful laser for treating purple lesions such as leg veins and birthmarks.

The Candela GentleYAG laser has become our most useful laser for red or purple facial veins and small to moderate sized leg veins.

What is the advantage of the new lasers?

The lasers allow for the length of time the laser light is delivered (pulse duration) to be varied. The longer the pulse duration, the less purple discoloration is produced at the time of the procedure.

How does the vascular laser work?

The science behind vascular laser treatments is complex but it they basically heat up the target vessel with energy from the light of the laser. The wavelength or color of the light determines how much the blood will absorb the light. Think of this as a red balloon inside of a blue balloon. The specific laser light will pass through the blue balloon without popping it and be absorbed by the red balloon and thus popping the inside balloon. The other factor in determining the effectiveness of the laser is how long the laser is turned on with each pulse. If the laser delivers too long of a pulse, there is too much heat and more than the target is damaged. If too little heat is delivered, the target will not be damaged. These lasers deliver an exact pulse designed to only damage the target vessel and none of the surrounding tissue.

What conditions are treated with the vascular lasers?

These lasers were first designed to treat childhood port-wine stains. These purple birthmarks were unable to be treated prior to this class of lasers. The Candela pulsed dye laser was the first laser to effectively treat even young children with this disorder.

Port-wine stains:

Facial blood vessels:

Facial telangiectasias:

Rosacea:

Leg veins:

Scars:

Warts:

Stretch marks:

Are these lasers safe?

When used by an experienced laser operator, these lasers have a tremendous safety record. There is very little risk of skin lightening and almost no risk of scarring.

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What is a brown spot?

Brown spots are sun damaged areas that are also called "age spots", "liver sots" and "lentigines". These are localized collections of pigment within the top layers of the skin.

These are more common as a person ages. The most common areas are the hands and the face but the arms and legs may also have these spots.

How may brown spots be removed?

The brown spots have been removed with creams containing Retin A, Alpha-hydroxy acids and Vitamin C. They also may be removed with chemical peels and our new microdermabrasion. Laser is also very effective in removing the spots, especially deeper and darker spots.

What lasers may be used to remove brown spots?

The Candela GentleLase Laser has become one of the most useful lasers to remove brown age spots.

The Candela Vbeam Perfecta Laser also has a pigment lesion handpiece that is effective in removing age spots.

The Pixel Laser and the Intense Pulse LIght machine also have a place in the treatment of brown spots, especially in larger areas such as the chest and arms.

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Sublative Rejuvenation - A Unique Technology

Smooth Out the Lines of Time

Wrinkles
Scars
Textural irregularities
Tone
Superficial skin lesions

Background

The eMatrix is what we call a fractional radiofrequency device. This means that energy in the form of radiowaves is used to heat the middle layer of the skin to help treat various conditions. As shown in the figure below, the radiofrequency(RF) comes out of 64 small electrodes and returns to the device by way of the outside electrodes.



Although the device is called eMatrix, the treatment is now called sublative. This term comes from the process of delivering most of the heat to the dermis (the middle layer of the skin) without damaging the surface. This process is called sublative resurfacing.

This device originally was designed to treat wrinkles. We have been very successful in refreshing the skin.

The following photographs demonstrate treating wrinkles on the neck:





The following photographs demonstrate treating wrinkles around the eyes:





We have found the Sublative procedure to be more effective in treating acne scars than any other treatment we have ever performed. The results as shown below are nothing less than remarkable.

Acne scars on the cheeks:





Acne scars on the temple:





The Sublative procedure has also been effective in treating large pores and general textural changes in the skin:

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Background

Evolastin™ is a new non-surgical facial treatment that places measured radio frequency energy directly into the deep dermis, stimulating the production of collagen and elastin - the very proteins that keep your face looking its youngest. Safe and effective for all skin types, evolastin™ improves skin’s tone, volume and elasticity after just one treatment.

Procedure

The Evolastin™ procedure involves the insertion of five pairs of insulated micro-needles that deliver energy to maintain a fixed temperature for 4 seconds. The heat generated damages the old collagen that is present in the middle layer of the skin (dermis). The insulation on the needles protects the surface layer of the skin (epidermis).









We have had extremely good results by adding volume and elasticity to the skin.

Figure 1 Before and After





Figure 2 Before and After





Figure 3 Before and After

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Sublime™ Skin Contouring

The evolution of ReFirme™ treatment for skin contouring.

The FDA-cleared Sublime™ Applicator offers virtually painless and fast treatment for wrinkle treatment and skin contouring. Conventional skin treatments are time - and treatment - intensive and often too painful for many patients. With Sublime™, you can have firm and contoured skin without surgery.

Sublime™ is ideal for targeting those telltale signs of aging, including sagging under the eyes, saggy brow lines, and nasolabial folds.

The photo below shows the right half of the face treated with Sublime™ and the other side untreated. This was after one treatment.









These photos are another patient treatment with Sublime™, there were 3 treatments each 3 weeks apart.

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What is Botox?

Botox is a purified, diluted product derived from the botulism bacterium. This is a substance that disables nerves that supply muscles. In the treatment of wrinkles, very tiny amounts are used.

Botox was first used to treat spasms of the eyes and it was noticed that wrinkles also would be removed.

Studies were then conducted to evaluate all of the uses for cosmetic purposes.

What areas may be treated?

The wrinkles to the outside of the eyes, called "crows feet", the central forehead wrinkles between the eyebrows and the forehead wrinkles are all excellent areas to treat.

There are times when the wrinkles of the neck are also treated with Botox injections.

What is the technique for removing wrinkles?

"Crows feet wrinkles" or smile lines:

Despite a good skin care program, the appearance of wrinkles will become more apparent through the natural aging process. Extended exposure to the sun, wind and dryness will accelerate this process. All of these factors are even more prominent in Colorado’s environment.

Smiling makes these wrinkles more noticeable. Very small injections of Botox into the small muscles of the temple will remove these wrinkles.

"Frown lines":

"Frown lines" are names for those unwelcome lines that tend to find their way onto your central forehead between the eyebrows. Many people think they appear to be angry when they are just concentrating. Injection of tiny amounts of the Botox into this central area will reduce or remove these creases.

Forehead creases:

Many patients have prominent furrowing of the forehead. This often feels like tension or looks as if the patient is frowning. Injecting the Botox to the outside wrinkles will remove the furrows all across the forehead. Many patients feel there is no longer tension in this area after the treatment.

How long will the treatment last?

The fact that Botox is not permanent is the best and the worst thing about the treatments. No one would probably want to use this if the treatment were not reversible. If there happened to be an effect that was not pleasing, this will always resolve within four months.

The expected length of the Botox effect is about four months after the first treatment. The effect lasts up to six months after the second and six to twelve months after the third treatment.

Is this safe?

The only expected side effects are bruising at the site of the injections. There are some occasions where the upper eyelids will droop if the Botox is placed too far from the mid line of the forehead. This is usually prevented by a conservative approach to the treatment. I have not experienced any other problems with this technique.

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What fillers are available and who performs the service?

Juvederm is a highly cross-linked hyaluronic acid injectable gel used for facial contouring/ rejuvenation by volumizing moderate to severe wrinkles and correcting deeper folds. There are usually no significant side effects except redness or bruising at the injection site. Juvederm XC is a new formulation of hyaluronic acid that incorporates the local anesthetic Lidocaine. This significantly decreases pain and discomfort during and after the injection which can be performed without a nerve block. It is primarily used in the smile lines, marionette lines, vertical lip lines and to better define the lip border. This filler may last six to twelve months in the smile lines and four to six months in the lips.

Prevelle Silk also incorporates Lidocaine and is used for the same locations. Find out more at www.juvederm. com or www.prevelle.com.

These injections are performed by our physicians and physician assistants.

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Why are leg veins enlarged?

The unsightly surface veins on the legs may have many causes. Most of the enlarged leg veins are due to underlying hereditary problems made worse by daily physical strains and stresses to the lower legs.

The basic underlying cause is the failure of the valves in the deep larger veins to prevent the backwards flow of blood. In normal veins, the valves only allow the blood to move forward toward the heart. If the valves function improperly, the blood will flow backwards, putting more and more pressure on the distant small veins. These will eventually enlarge, causing the visible surface veins that are unwanted. These are not “broken”, they just have more blood than desired. These are also not necessary veins. The legs have many collateral veins so the removal of some unwanted surface veins will not damage the circulation of the lower legs in any way.

What is sclerotherapy?

Sclerotherapy involves the injection of a chemical into the veins that are to be removed. The chemicals scar (sclerose) the inside of the vessel so it no longer carries blood. The chemicals usually used are a very concentrated saline (NaCl) solution, Polidocanal or Sotradecol.

What type of leg veins may be treated with sclerotherapy?

Leg veins that are blue or red and up to 2 mm in diameter are easily treated with injection sclerotherapy.

Larger reticular veins usually respond better to Sotradecol injections.

Is treatment permanent?

Since we are just treating symptoms of deep vessel abnormalities, few of these treatments are likely to be permanent. Hopefully, the unwanted leg veins will disappear and remain gone for years. We still consider the treatment of leg veins to be a maintenance procedure because either new vessels will appear or old vessels may eventually recur.

What are the side effects?

Most patients will have slight discomfort with the injections and some bruising. There may be some brown discoloration that could last up to 8 weeks after treating larger veins. Matting, a new growth of fine red vessels is the most worrisome risk. This appears in about 10 percent of sclerotherapy cases. In the rarest of instances, there have been ulcers and scars at the site of some injections. If this were to occur, laser is helpful in resolution.

Do you have to wear compression stockings after the treatment?

After saline or pokidocanal injections, it is best to wear the compression stockings for 2 - 3 days. After treating the larger veins with sotradecol, the compression hjose must be worn for 6 weeks.

What is the cost for a treatment and will insurance cover this?

The cost varies by the amount of the veins to be treated and usually ranges from $200 to $300 per visit. Insurance rarely covers this treatment because it is a cosmetic procedure.

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What lasers are useful in treating unwanted leg veins?

In our office we have both a Candela Vbeam pulsed dye laser, a Candela GentleYAG laser and a Candela GentleLase laser that are all used for treating leeg veins.

There are a large number of other lasers used to treat leg veins including Argon lasers, other pulsed dye lasers, Krypton lasers, Diode lasers and Intense Pulsed LIght machines.

There are pros and cons to each laser but we have chosen our lasers for specific reasons. The Candela pulsed dye laser was the original laser used to treat vascular abnormalities. Since our first pulsed dye laser in 1989, there have been many improvements leading to the Vbeam Perfecta laser. This laser is now, by far, the most effective laser for a very wide variety of blood vessel abnormalities. The GentleLase and the GentleYAG have proven safe and effective for leg vein treatment.

Describe laser surgery to treat leg veins.

Laser surgery involves using a laser to destroy the unwanted blood vessels. The heat from the laser damages the vessels, so they will not hold blood. We use the Candela Vbeam pulsed dye laser for finer red vessels and the Candela GentleLase Alexandrite laser for slightly larger blue veins. The Candela GentleYAG may be used for both small red veins and larger blue veins.

All of these lasers use a Dynamic Cooling Device (DCD) that sprays a coolant on the surface of the skin just prior to pulsing the laser. This markedly decreases the discomfort of the laser treatment. This also protects the surface of the skin and allows treatment of slightly tan skin without side effects.

A cooling gelatin dressing is applied after the laser treatment and is kept in place for several hours.

What are the side effects of laser surgery for leg veins?

There is minimal discomfort with our laser because we use cooling spray found only on the Candela lasers. A purple bruise-like discoloration is present at the site of the laser treatment. This may remain up to eight weeks. The bruising is far less with the GentleYAG laser than with the other lasers. There is some risk of a brown discoloration that may last several months. Rare patients have had persistent lightening of the skin after laser treatment. This is usually with darker skinned patients or those with a significant tan.

Is this treatment permanent?

Just as with sclerotherapy, we are usually treating only the symptoms of a deeper vein abnormality and few of the treatments are expected to be permanent. The results are very satisfactory but must be maintained. These before and after photos demonstrate this.

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Why is there unwanted hair?

The causes of excessive hair growth pattern are many and varied. The most common causes include:

• Heredity

• Pregnancy

• Glandular and/or hormonal imbalances

• Reactions to certain medications

• Normal aging processes

There are other causes of excessive hair growth, including excessive waxing, tweezing and other temporary methods of hair removal (creams/depilatories), among others.

How may the hair be removed?

Historically, hair was removed by shaving, waxing, plucking or electrology. We now use advanced lasers to remove the unwanted hair.

Topical Vaniqa® may also be used to remove unwanted hair. We use this for light colored facial hair.

What lasers have been used for hair removal?

Nd:YAG lasers with Carbon Gel:

One of the earlier lasers worked on the concept that after waxing, carbon gel was rubbed on the leg forcing the gel into the "empty" hair follicles. The light from the laser then would then be absorbed by the gel, damaging the hair follicle. This laser did not end up working well at all for this condition.

Ruby lasers:

There are several long pulse ruby lasers that have been shown to be effective in laser hair removal. The possible disadvantages include a small laser spot size and slower treatments. Although some studies may show this no to be the most effective laser, it is still a useful tool in some settings.

Diode lasers:

These lasers are also somewhat useful but have the disadvantages of much small spot sizes and much slower treatments. Some of these lasers have been shown to be more effective in tanned or darker skinned patients.

Alexandrite lasers:

The Candela GentleLASE(TM) is a long pulsed alexandrite laser that has been shown to be very effective, fast and safe for permanent hair reduction.

Long-pulsed Nd:YAG Lasers:

The Candela GentleYAG(TM) is long pulsed Nd:YAG laser that has been shown to be effective in permanantly reducing hair, especially in dark skin.

How Do The Lasers Work?

The laser light is a specific wavelength of light that passes through the surface of the skin and is absorbed by the growth bulb of the hair. This damages the growing hair but not the surrounding tissue. Therefore, the growing hair is destroyed and will not grow again.

Is Laser Hair Removal Permanent?

Laser methodologies have now been proven by the Food and Drug Administration to offer permanent hair reduction. This means hat the number of hairs will be reduced but ALL hair is not permanently removed. Some areas are more effectively treated and some colors of hair are more responsive to laser treatment.

Which body areas can be treated by laser hair removal?

The GentleLase procedure has been used successfully to treat thousands of patients, permanently removing unwanted hair on large areas such as legs, arms, and chest. Sensitive areas such as the eyebrow, upper lip, ears and even bikini lines can be easily and effectively treated by GentleLase. Back hair appears to be the most difficult area in which to effectively remove hair.

How many laser hair removal treatments are required?

All patients will require at least four laser treatments. This is because the first treatment only eliminates the active hair follicles. Everyone has hair that is in an inactive or "sleeping" state. These hairs will generally start growing after the initial active hair is eliminated. Approximately 4 to 6 weeks after the initial treatment, a second treatment is required to eliminate the remaining hair shafts. Depending upon hair type and genetic factors, some patients may require several additional treatments beyond these initial treatments. Almost all patients, even those with extremely persistent hair growth, will achieve permanent hair reduction after four or five treatments.

Is laser hair removal treatment painful?

In one pulse, the GentleLase laser removes all the hair on a patch of skin the size of a nickel. The pulse, lasting only millionths of a second, is no more painful than plucking a single hair.

As an additional design benefit, the GentleLase system combines a pulse of cooling spray that dissipates the small level of heat generated by the laser. This makes GentleLase the most effective and most pleasant technique available for hair removal.

You will see and feel the real benefits to the GentleLase technique after the treatment. Unlike tweezers, chemicals or needles, no irritation occurs after the treatment. The skin is left smooth and silky with minimal side effects.

Risks, side effects and possible complications of laser hair removal treatment

The possibility exists that some side effects or complications can occur, including:

• Itching, during treatment

• Pain, tingling, or feeling of numbness (cold spray)

• Crusting/scab formation (on ingrown hairs)

• Bruising (rare)

• Purpura (purple coloring of the skin) on tanned areas

• Redness

• Swelling

• Infection (uncommon)

• Temporary pigment change (hypo-pigmentation or hyper-pigmentation)

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What types of chemical peels are available from the esthetician?

We use both glycolic acid (alpha-hydroxy acid) and Salicylic acid ( beta-hydroxy acid) peels.

Describe the procedure.

A clear, "water-like" solution is applied to the face with a small brush or sponge. This liquid is left in place for 1 - 5 minutes, depending on the desired depth of peeling. A neutralizing solution is sprayed on the skin that immediately stops the peeling process.

A "post-peel" cream and/or a sunscreen is then applied to the treated area.

Additional peels may be spaced 1 - 2 weeks apart.

Are there any side effects?

Mild flaking, superficial crusting and tightness may occur for up to 7 days following a chemical peel. Sun exposure should be avoided as much as possible during this time.

Superficial peels may stimulate an outbreak of herpes virus in those individuals already carrying the virus. These individuals may be given a medication prior to the peel to suppress the virus.

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What is microdermabrasion?

Microdermabrasion is a non-invasive and non-surgical procedure that sprays a stream of fine crystals directly on the skin. This crystal spray removes the surface layers leaving a smooth, fresh rejuvenated skin surface.

What conditions may be treated with microdermabrasion?

The following conditions may be treated with this technique:

• Sun Damaged Skin
• Fine Wrinkles
• Acne Prone Skin
• Age Spots
• Oily Skin
• Acne/Acne Scarring
• Melasma

How many procedure are needed?

The average patient requires between 5-9 treatments, spaced one week apart.

Are there any side effects?

The procedure is almost pain-free and leaves the skin with little or no redness. Patients are usually able to return to the home or office immediately after the procedure.

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What is a blue peel?

The Obagi Peel is an in-office procedure designed to significantly improve the appearance and health of your skin. This may be used with the Obagi Nu-Derm system or without. Dr. Obaji developed a technique for applying trichloacetic acid (TCA) to the skin in a safe and consistent manner. The blue color is part of the base in which the acid is applied.

Unlike Glycolic Acid and Alpha Hydroxy peels, the OBAGI Blue Peel uses a slow-acting TCA (trichloroacetic acid) solution applied to the skin to remove dead skin cells and stimulate the production of new skin cells. Since TCA is not absorbed through the skin, there are no internal toxic effects. The slow action of the OBAGI Blue Peel solution enables your surgeon to control the peel process and its depth. It tightens the skin, reduces wrinkling and renews a more youthful appearance.

Who is a candidate?

Anyone who wants to look better and reverse the appearance of the aging process. Those who have blemish-prone skin, wrinkles, pigmentation problems, sun damage, or general poor skin quality will benefit the most.

The program is specifically designed to correct:

• Pre-Cancerous Lesions
• Uneven Pigmentation
• Unsightly Blemishes
• Sun Damaged Skin
• Some Fine Wrinkles
• Photo-aged Skin
• Age Spots
• Acne
• Large Pores

How do I prepare the skin for a peel?

Patients are on the Obagi Nu-Derm system to prepare the skin. These products are individualized to each patient depending on their skin type. Several weeks of pre-treatment will help the chemical peel be more effective.

What areas may be treated?

Unlike laser peels, OBAGI Blue Peels can be performed on the face, neck, chest, hands and even the arms and legs.

Describe the procedure.

OBAGI Blue Peel take 25 to 30 minutes and are performed on an out-patient basis in your physician's office, usually without sedation. If your physician indicates sedation, you will need someone to drive you home. Depending on your skin type and the desired results, you will probably require from 1 to 4 coats of OBAGI Blue Peel solution applied to various areas of skin.

Most patients experience a warm to hot sensation, which may last as long as 2 to 3 minutes, followed by a stinging sensation.

Immediately after the procedure, a bluish tint remains on your skin, which will usually wash off in 12 to 24 hours.

What happens after the peel?

After the procedure, you will experience light swelling, and your skin will begin to peel within 2 to 3 days. This peeling will continue over the next several days and should be healed in an average of 7 to 10 days. If you are having a lighter, exfoliative Blue Peel, healing is completed in 3 to 6 days. In either case, this peeling should not disrupt your normal lifestyle.

Can I perform the peel myself?

No, the Obagi Blue Peel is a medical procedure and MUST be performed by a physician or a properly trained specialist working under his/her supervision.

Can I apply make-up after an Obagi Blue Peel?

Generally, make-up is not recommended for the first 7 to 10 days or until the skin has completely peeled. More specific information will be supplied by your health care professional.

What type of products should I use on my skin after the Obagi Blue Peel?

Obagi NU-DERM Products which promote skin health through correction and stimulation are recommended with Obagi BLUE PEEL. These products will prolong the effects of the peel.

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