BB&T Contributing Writer

CHICAGO – Lasers, not diamonds, have become a girl's new best friend. From treating discolorations, acne, scars, hair removal, smoothing the skin, to tightening up the face – all can be done without surgery and non-invasively by using the specific laser for the task at hand. These techniques as well as a host of other non-surgical cosmetic procedures were demonstrated at the summer meeting of the American Academy of Dermatology (AAD) (Schaumberg, Illinois), held here in August. Cosmetic surgical procedures have decreased since 2008, with the economy primarily being blamed; but dermatologic non-invasive procedures are alive and well, especially laser treatments for facial rejuvenation and enhancement (see Table 1).

There were about 10 million surgical and nonsurgical cosmetic procedures performed in the U.S. in 2009, as reported by the American Society for Aesthetic Plastic Surgery (ASAPS); and of those, only 15% were surgical with nonsurgical procedures making up 85% of the total. Additionally, the American Society of Plastic Surgeons (ASAPS; Arlington Heights, Illinois) reported that the demand for minimally invasive cosmetic procedures grew by 5% to 10.4 million procedures in 2008 while surgical procedures fell 9% in the same time period. Although the corner was turned in 2008 where non-invasive procedures exceeded invasive procedures in numbers, the trend had been creeping slowly towards non-invasive; and with the help of the recession, has now resulted in more requests for the less invasive, less costly procedures. This movement in patient demand from invasive to less invasive procedures marked an unheralded opportunity for laser manufacturers. A bumper crop of lasers entered the market to treat wrinkles, hyperpigmentation, laxity, acne, hair removal, or scars. The beauty (pun intended) of it all is that no one laser can treat all of the conditions, so a variety of wavelengths and intensities of lasers emerged to address each concern (see Table 2).

In a symposium titled “What's Hot in Skin Resurfacing“ Dr. Mathew Avram gave the presentation of Elizabeth Tanzi, MD, Assistant Professor of Dermatology, Johns Hopkins Medical Center (Baltimore) who at the last minute could not make the meeting. Reading from her script, he said, “Years of damaging ultraviolet light exposure manifests clinically with variable degrees of dispigmentation, wrinkling, and laxity, and are usually amenable to treatment with a variety of ablative and non-ablative lasers. The most appropriate treatment technique is dependent on the severity of the photodamage and the expectations and lifestyle of the individual patient.“ He continued, “For years, fully ablative laser skin resurfacing (LSR) with the carbon dioxide laser (CO2) was the gold standard in skin resurfacing. Developed in the mid-1990's, traditional ablative LSR demonstrated excellent efficacy but the popularity of the procedure waned due to extended post-op recovery, permanent hypopigmentation, and persistent erythema. “

To avoid the problems associated with ablative lasers, a number of non-ablative lasers were subsequently introduced including KTP, Nd:YG, diode, and intense pulsed light in order to shorten recovery but still stimulate collagen production. “Although each of these systems demonstrated histologic changes in dermal collagen, a series of treatments often yielded limited clinical improvement,“ according to Tanzi. In 2004, an innovative concept called fractional photothermolysis was introduced that involves the creation of microscopic thermal wounds interspersed with non-treated skin. Tanzi wrote: “The intact non-treated skin forms bridges between the microscopic treatment zones, thereby leading to rapid healing. The wound healing response differs from fully ablative techniques because the epidermal tissue that is spared between the thermal zones contains viable transient amplifying cells that are capable of rapid reepithelialization.“ This resulted in very short down time where the skin appeared bronzed; but even after a series of treatments, the improvements were limited compared to ablative LSR.

“A continued desire for superior clinical results while maintaining a manageable recovery time gave rise to the combination of ablative laser devices that adhere to the concept of fractional photothermolysis. Ablative fractional resurfacing with either a CO2 or erbium:YAG laser ablates to a far greater depth than non-ablative lasers, resulting in greater tissue contraction and collagen stimulation,“ said Tanzi. By marrying the aggressiveness of CO2 and erbium:YAG lasers to the fractional application, good results with limited down time was finally achieved. In addition, due to the fact that fractional ablation is less intense, non-facial areas can now be treated, such as the neck, chest, hands and eyes.

Ablative fractional photothermolysis is now the current trend and one might call the gold standard for treating laxity and deep wrinkles for patients who want a more dramatic effect. Other lasers and radio frequency (RF) devices also employ the fractional thermolysis approach but are used for fine lines, pigmentation, hair removal, acne, or mild laxity – depending on the patient's requirements.

An example of fractional energy delivery using bipolar RF energy to deliver the thermal injury is that employed by Syneron Medical (Yokneam, Israel). According to Marian Northington, MD, assistant professor of dermatology, University of Alabama (Birmingham, Alabama), “Fractionated bipolar radio frequency energy shows promise for skin tightening and moderate lifting of the lower face.“ Much like fractional laser resurfacing, heat energy is delivered to the dermis in a pattern of microscopic zones that are spaced in a grid. The non-treated zones of uninjured surrounding tissues serve to promote safe and rapid healing. Through the wound healing process, tissue contraction and skin tightening are observed,“ said Northington. Syneron introduced the first RF-only, non-laser, non-light device that's FDA-cleared for fractional resurfacing.

The first company to introduce monopolar RF energy for use on the face for skin tightening was Thermage, now owned by Solta (Hayward, California) who purchased them in 2008 along with Reliant Technologies, the pioneer of fractional laser resurfacing and developer of the Fraxel platform of lasers. Thermage uses capacitive coupling in a non-invasive monopolar RF procedure, while Fraxel offers a variety of fractionated lasers, each for a different purpose. Solta later went on to purchase Aesthera in 2010 that holds the only laser- or light-based devices with FDA clearance for the treatment of acne. These acquisitions position Solta in all three of the fastest growing segments of the cosmetic laser industry.

Table 1

By far, the most popular use of lasers in cosmetic applications is for hair reduction/removal with well over a million procedures performed last year in the U.S. In order to capture these patients and then be able to offer other treatments as well, many physicians are finding that they need to own more than one type of laser (see Table 3). Each component in skin tissue has its own unique absorption spectrum that determines what wavelength of radiation will be absorbed to produce a given therapeutic/cosmetic effect. Since different wavelengths of lasers are better suited to serve one application over another, platform devices have become popular among purchasers so that they can have one device with multiple lasers and applications; much like an all-in-one copier, scanner, printer and fax machine with which we are all familiar. In addition, physicians have struggled to find treatments that could deliver significant noticeable results for all skin tones while remaining gentle enough to prevent adverse events. The most common dermatological concerns for patients with darker skin tones, which include African-American, Asian, Hispanic, East Indian and other darker skin type patients, are scarring and discoloration. By owning a multi-platform device, not only are a variety of applications available, but also the ability to treat a variety of skin tones.

Multiplatform lasers can combine several different lasers and/or energy systems into one console, with the exception of a CO2 laser that requires its own console. CO2 is also the only laser where all 50 states require a licensed medical doctor to operate it. Other lasers, depending on the state, may be operated by trained non-physician personal. Companies that offer multi-platform laser systems include Syneron, Cutera (Brisbane, California), Palomar Medical Technologies (Burlington, Massachusetts), Alma Lasers (Buffalo Grove, Illinois), and SharpLight Technologies (Rishon LaZion, Israel) to name a few.

Select top laser companies in cosmetic dermatology

Syneron Medical, who acquired Candela (Wayland, Massachusetts) for about $65 million in an all-stock deal that closed in January, said revenue for the second quarter 2010 was $48.6 million, a sequential increase of 13% compared to $43.0 million in the first quarter 2009. Syneron developed the “combined“ IPL technology with bipolar RF to create electro-optical synergy or els as it is now known. Syneron, after acquiring Candela, claims to offer the broadest available product portfolio, a worldwide service organization, an expansive global distribution network. Most of their sales are from outside the U.S., with only about 35% of their sales coming from the U.S.

Cutera (Brisbane, California) was founded in 1998. They have installed more than 4,000 systems and offer individual as well as multi-platform lasers from IPL to ablative fractionated YSGG, a new wavelength used for similar applications as those used by a CO2 laser. By using the YSGG instead of CO2 for fractional ablative procedures, they can incorporate a deep wrinkle application into a multi-platform device.

Formed through the merger of ESC Medical Systems and Coherent Medical Group, Lumenis (Santa Clara, California) boasts a sales presence in more than 100 countries worldwide and has the world's largest installed base of more than 80,000 systems. They participate in the surgery, ophthalmic and aesthetic market sectors, with the largest portion of their business (37%) coming from the aesthetics sector.

Palomar Medical Technologies, founded in 1991, has shipped 5,000 systems, mostly in the U.S. They offer lasers and IPLs for skin rejuvenation, hair removal, skin resurfacing, and body contouring.

Alma Lasers was founded in 1980 and focuses only on cosmetic lasers, light-based, RF and ultrasound devices. Their mission is to provide modular, cost-effective systems that enable practitioners to offer safe, effective and profitable aesthetic treatments to their patients.

Cynosure (Westford, Massachusetts) develops and markets aesthetic treatment systems to the dermatology, plastic surgery, and general medical markets. Its systems incorporate a range of laser and other light-based energy sources, including Alexandrite, pulse dye, Nd:Yag, and diode lasers, as well as intense pulsed light. Cynosure sells its products through a direct sales force in North America, France, Spain, the United Kingdom, Germany, Korea, China, and Japan, as well as through international distributors in 71 other countries. The company was founded in 1991.

Deka (Calenzano, Italy) manufactures and markets lasers and pulsed light equipment not only for aesthetics but also for surgery, dentistry and neurophysiology in more than 60 countries all over the world.

Sharplight Technologies' product lines are designed for a range of applications, from skin rejuvenation and hair reduction to the treatment of vascular and pigmented lesions and acne. SharpLight is part of the American Laser Clinics (AML) group, a medical services provider with one of the first private chains of aesthetic medical centers in the world.