Lasers: What to choose, what to use

National report - Since no laser or light source meets every patient's needs, experts say it's crucial to choose technologies that will provide the maximum utility in a given practice setting.

This is especially important when choosing one's first or second laser, says Arielle N. B. Kauvar, M.D., director, New York Laser & Skin Care.

"Choosing your first laser can be quite a daunting challenge," she says. However, she says that taking a methodical approach simplifies the decision.

Product versus platform

"The first thing to understand is that there is a difference between a single laser and a platform," which consists of a base unit with removable attachments to provide treatments at different wavelengths, she says.

Many intense pulsed light (IPL) systems come as platform devices that accept laser attachments, she says, and even single-wavelength devices possess multiple applications. Other options include popular dual-wavelength combinations such as 532 and 1,064 nm or 595 and 1,064 nm.

Key considerations in choosing a laser include practice demographics. For example, elderly patients would likely require treatments for sun damage and skin cancers, while serving a younger patient population might drive one toward lasers that excel in treating acne.

Specifically, Dr. Kauvar says that if one has a large acne and rosacea practice, one can use IPL, with or without photodynamic therapy, to treat both conditions.

For practices that want to stick with one device, she adds, "Consider an IPL, pulsed dye laser or KTP laser," all of which can treat both vascular and pigmented lesions. Conversely, she says treating tattoos requires additional lasers - namely a Q-switched Nd:YAG and a Q-switched alexandrite or ruby.

To help determine patients' needs, she recommends using an office questionnaire that asks not only which treatments patients might like, but in what order of priority and how much they're willing to pay for these services.

Strategically, Dr. Kauvar says one also must consider whether or not services patients desire are readily available from other practices in one's local market.

Other considerations include whether one can rely on referrals from local practitioners or will attract cosmetic patients mainly from an existing medical practice, she says.

"Most importantly," says Dr. Kauvar, "consider your monthly budget. Individual devices cost $50,000 to $100,000."

Accordingly, she recommends calculating how many procedures you'll have to perform to break even on each device.

Regarding payment methods, she says renting allows small or new practices to test devices without making long-term commitments.

"However, the cost of renting is high - usually $1,000 per day per laser."

Leasing - which costs approximately 0.03 times the product's purchase price per month - is more popular, she says. One potential drawback here is the quick pace of progress, which makes it important to consider whether the device one leases has a future beyond its three- to five-year contract.

Dr. Kauvar also strongly recommends post-warranty maintenance contracts, which can cost $5,000 to $10,000 or more per device annually.

"These are fragile devices, and they do break down," she says.

No ’easy’ button

When it comes to laser and light-based treatments, "We're all looking for the easy button. Everyone wants maximal results with minimal downtime, cost and pain," says E. Victor Ross, M.D., director of laser and cosmetic dermatology, Scripps Clinic, San Diego.

However, he says no system satisfies all these requirements. Therefore, Dr. Ross states that key to a successful aesthetic laser practice is matching the treatment to the indication - factoring in patients' needs, as well as the physician's experience level and preferences.

"The laser I use most is my KTP laser because 50 percent of the people who come to my clinic have red and brown spots. It's the most valuable laser in my practice simply because I use it the most," Dr. Ross says.

In addition, he says he values its predictable results. IPL devices are well-suited for red and brown lesions as well, he says, "And their bigger spots allow for rapid treatments."

Other lasers he uses almost daily include a Q-switched alexandrite (for indications including tattoo removal and pigmented lesions), a long-pulsed alexandrite for hair removal, and a pulsed dye laser (PDL) for red lesions, striae, marks and scars. His nonablative fractional lasers (1540 nm, Palomar; Fraxel re:store, Reliant) also see regular use.

"The hottest new item in facial rejuvenation in the past couple years is nonablative fractional remodeling," he adds.

Key to its popularity is the fact that because this technology is nonablative, many patients who weren't candidates for more traditional resurfacing can undergo some form of facial rejuvenation, including scar remodeling, Dr. Ross says.

When the procedure is properly managed, he adds, "Downtime and pain are fairly minimal."

Ablative fractional resurfacing also scores high marks from Dr. Ross - with the caveat that many patients won't be suited for this procedure because it requires three to 10 days' downtime.

However, he says, "You can probably do more with one treatment using ablative fractional technology versus a nonablative technology, which almost always requires multiple treatments."

Additionally, he says, "Visible light technologies - be they IPL devices, PDLs or KTP lasers - still enjoy a prominent place in overall skin rejuvenation because they can target blood vessels and pigment."

Regarding ablative technologies, Dr. Ross says they remain important, but they're harder to use than nonablative modalities and cause downtime most patients find intolerable.

"What nearly killed conventional CO₂ laser resurfacing years ago was delayed hypopigmentation," which typically occurred because physicians performed multiple passes, failed to use feathering techniques or treated darker-skinned patients the same way they treated light-skinned patients, he says.

Although fractional technologies have eliminated many of these problems, he notes that because CO₂ treatment parameters have been significantly modified over the past 10 to 15 years, "There's still a role for conventional CO₂ resurfacing."

In fact, he says, "If my clinic were burning and I only had time to save two lasers, I'd save my KTP laser and my CO₂ laser. They do very different things, but they're the yin and yang" that allow him to cover the widest range of indications with the fewest lasers.

If he had time for a second run, Dr. Ross says, "I would go back and get my IPL and PDL because they are MVPs as well."

Conversely, he says skin tightening devices are less valuable to him, "But not because they're bad technologies." Rather, he says that products such as the Titan (Cutera), Polaris (Syneron) and ThermaCool (Thermage) face a tremendously difficult challenge.

"We're trying to heat the skin from the surface confluently while preserving the epidermis" and creating skin tightening underneath. Under these conditions, "The best we can hope for is very modest, gentle skin tightening in most patients."

According, Dr. Ross says that if patients are expecting surgery-like results from tightening technologies, "They're going to be disappointed." DT>

Disclosures: Dr. Kauvar has received research grants from Candela and Cutera and is a consultant for Palomar, Lumenis and Sciton. Dr. Ross has received research grants and equipment from Cutera, Candela, Lumenis, Sciton and Palomar, and equipment from Alma.