A Guide to Lasers and What’s Right For Your Skin
A board-certified dermatologist and clinical assistant professor of dermatology at the NYU School of Medicine, Dr. Robert Anolik is a prominent cosmetic dermatologist and researcher in New York whose knowledge of and experience with the newest skin-improving technologies in multiple areas of dermatology—from lasers to radiofrequency to Wrinkle Relaxers and fillers—is enormous. Beyond being a goop favorite, he’s a recipient of Elle Magazine’s Genius Award (they dubbed him “The Techie”), and a Rising Star in the New York Times Magazine “New York Super Doctors” feature, he’s quoted often in the consumer press, the author of numerous academic articles, and lectures frequently on the subject of laser surgery, cosmetic dermatology, and Mohs surgery. Here, he explains which laser does what, along with how best to address common skin issues, from aging to rosacea:
A Q&A with Robert Anolik, M.D.
Are there anti-wrinkle lasers, per se? Which are best for for skin texture issues? Do you believe that lasers are the best approach for crepe-iness?
In general, lasers that remodel collagen and stimulate collagen production throughout the dermis of the skin improve the appearance of wrinkles, texture, and crepe-iness. This is because the first two relate to weakening or irregular conformations of the dermal collagen, while the latter is a result of thinning of the dermal collagen. Remodeled and new collagen normalizes this layer so that it is more organized, more even in distribution, and deeper in depth.
There is a surprising misconception that lasers take off the top layers of skin, leaving it white, and/or shiny/thinned. This is not the case. I suspect this mistaken patient belief relates to older methods of rejuvenation like dermabrasion, deep chemical peels, and old-fashioned lasers, all of which did remove surface layers of skin and carried a risk of removing all normal pigment cells called melanocytes. (Today, I still see patients in the office who were treated in the 80s, 90s, and early 2000s with these older methods, and some do have these unusual signs of treatment.)
Fortunately, rejuvenating lasers today generally penetrate the surface skin, stimulating the collagen from within and below and triggering its production, rather than simply shearing off the surface. This is because resurfacing lasers today are fractional—meaning that the laser beam is delivered in a pixelated manner, touching the skin in tiny dots, separated by areas of untreated skin. This leaves behind healthy pigment producing cells (melanocytes) and other normal skin cells unaffected by the treatment that rapidly heal the skin and markedly diminish the risk of abnormal pigmentation.
“There is a surprising misconception that lasers take off the top layers of skin, leaving it white, and/or shiny/thinned. This is not the case.”
The most commonly used lasers for these strategies are fractional resurfacing lasers. The most popular ones are those with limited downtime (generally from a few hours of pink and dryness to 4-5 days of pink and dryness). My currently used strategies include the non-ablative (non-wounding) Clear and Brilliant lasers and Fraxel Restore dual lasers. Not only do these lasers stimulate the collagen, they also allow for a surface exfoliation of the skin, which sheds abnormal browning and dullness to the skin. Consequently, the skin looks brighter.
The stronger lasers are ablative (meaning they superficially wound the skin), leaving the skin with redness and scabs for about a week, followed by 3-4 weeks of pink skin. The later 3-4 weeks can generally be masked with makeup, since the skin has healed. These stronger versions are usually reserved for more substantial signs of aging, uneven texture, deep wrinkling, or scars—often acne scars. My preferred ablative fractional laser is Fraxel Repair.
More good news about these therapies: I was part of a clinical trial published in 2012 that demonstrated the likelihood that these newer fractional laser treatments promote not just more beautiful skin, but healthier skin as well, by supporting the elimination of pre-cancerous skin changes known as actinic keratoses. These precancers have the potential to turn into squamous cell carcinomas.
“I was part of a clinical trial published in 2012 that demonstrated the likelihood that these newer fractional laser treatments promote not just more beautiful skin, but healthier skin as well, by supporting the elimination of pre-cancerous skin changes known as actinic keratoses.”
Finally, there is a very new method of collagen stimulation that benefits wrinkles, texture, and crepe-iness. It’s so new I imagine most people are not yet familiar with it: picosecond laser technology. It first appeared after the FDA approval for picosecond laser treatment of pigment, most notably tattoos. (It is called the Cynosure PicoSure laser, and the one I use in my office.) When I say picosecond technology, what I’m referring to is the rate at which laser energy is delivered to the skin. In this case, a beam of light at a certain energy is delivered within a picosecond, an extraordinarily rapid rate. I participated in clinical trials that studied the effects of these picosecond lasers when passing through a specialized diffractive lens. The lens ultimately delivered areas of peak energy and low energy, almost like a fractional laser, but there was always some low level of energy touching the surface of the skin. There are a number of theories as to why this laser technology helps remodel and produce collagen. One of the most interesting to me is that the rapid delivery of laser light might stimulate a vibration throughout the surface of the skin, triggering the collagen response. I have since been a part of publications and lectures describing the clinical trials we performed. What makes this science all the more interesting—and desirable for our patients—is the limited downtime. Usually the skin is just a bit pink for a few hours after treatment.
Which lasers fight redness and promote skin evenness?
Redness on the skin is caused by a number of things, including sun damage, genetics, hormones, and rosacea. Topical treatments include prescription drugs that are able to limit some underlying inflammation, like metronidazole creams and azeleic acids gels and sulfacetamide lotions. But the most effective method of reducing facial redness is laser therapy. The underlying concept is that specific laser wavelengths can be delivered to the skin in order to heat and eliminate blood vessels while leaving the surrounding skin structures (hair, collagen, pigment, etc.) untouched. These blood vessels are simply cosmetic nuisances—we are not eliminating medically important structures.
The gold standard of redness reduction for years has been the pulsed dye laser (example: VBeam laser). It’s so effective that we can use it to eliminate port wine stain birthmarks (like the one on Gorbachev’s forehead). I most often use it for redness reduction stemming from the common causes mentioned earlier but also port wine stains as well as the redness of scars (sometimes acne-related, or surgical or traumatic). Each condition should be treated differently; an expert cosmetic dermatologist will know which parameters and strategies are best used to treat different targets.
“It’s so effective that we can use it to eliminate port wine stain birthmarks (like the one on Gorbachev’s forehead).”
Newer lasers have emerged that complement these treatments—and can sometimes be the primary laser choice. These include KTP lasers (example: ExcelV laser). These lasers give us two different wavelengths of light that are distinct from pulsed dye lasers. These newer wavelengths can often better target the larger blood vessels that look like red lines/squiggles or blue paths on the face (google “telangiectasia” and “periorbital vein” to see examples of what I mean).
When I treat a patient’s redness, I look for both diffuse redness as well as more pronounced red/blue capillaries. Patients with redness usually have both. For these patients, I use both a pulsed dye laser and a KTP laser on the same day to achieve optimal redness reduction. It’s a very tolerable treatment, and feels like rubber band snaps over the face. Unpleasant but not painful. It usually only lasts a few seconds and the downtime is usually just a few hours of looking blotchy pink. Many of my patients don’t bother with makeup to hide the appearance, but patients can put makeup on afterwards if they feel it’s very obvious.
Which are best for tightening and fighting sagging?
The sciences that allow cosmetic dermatologists to tighten (i.e. fight sagging) skin is one of the fastest growing areas in our field. I am involved in a number of clinical trials using these technologies, and there are several very interesting strategies that seem to be improving daily.
It’s important to understand that not all technologies are lasers. Lasers are beams of light that are simply one wavelength. Other forms of energy can be used on the field of cosmetic dermatology, including radiofrequency and ultrasound.
Radiofrequency was one of the first technologies to help tighten skin. A popular system is Thermage. With this science, we can safely deliver radiofrequency energy into the skin to produce a heat throughout the underlying collagen fibers. This can stimulate remodeling of existing collagen and the production of new collagen. The result is a tightening/firming to the skin. This used to be a painful treatment, but innovations in delivery make it very comfortable. These strategies include vibration in the handpiece that touches the skin as well as cooling methods to comfort the surface skin.
“It allows me to safely deliver sound waves under the skin that focus to points at very specific depths. Think of the way a magnifying lens can take sunlight, focus that light onto a leaf, and leave a burn.”
Ultrasound is one of the newer technologies used in skin tightening and lifting. One of the popular systems in Ulthera. It allows me to safely deliver sound waves under the skin that focus to points at very specific depths. Think of the way a magnifying lens can take sunlight, focus that light onto a leaf, and leave a burn. With Ultherapy, ultrasound can pass right through the skin surface painlessly, but be focused to meet at a specific point at a specific depth under the skin. At this meeting point, the temperature goes up, stimulating collagen remodeling and collagen production. This procedure tends to be uncomfortable, but like the Thermage science, has become more comfortable with strategies that include lower energy delivery with more passes of the sound waves.
Finally, it’s important to realize that cosmetic injections of Wrinkle Relaxers and filler also allow me to lift skin. With Wrinkle Relaxers , I am able to strategically place it into muscles that have a downward pull. These muscles include those immediately below the forehead and above the eye. Ideal placement here gives people a noticeable brow lift. (Don’t worry about spock eyebrows— these are prevented by delicate placement of Wrinkle Relaxers in the forehead!) Wrinkle Relaxers can also be used in the chin to lift the corners of the mouth. And it can be injected into the neck to allow a lift to the jowls and neck bands.
“In the hands of someone other than an expert doctor, filler results in a full face—which is not the goal of filler.”
Filler injections also give the face a lift. In the hands of someone other than an expert doctor, filler results in a full face—which is not the goal of filler. True appreciation for the placement of filler allows contour and lift. Injections underneath facial muscles and in areas where the young face once had more significant, supportive bone and fat pads, give a natural-looking lift. No one will know you were treated, but the face is re-contoured and lifted to prevent the appearance of sagging skin and jowls.
While these techniques are very exciting and becoming more popular, I cannot say that we can achieve the lifting outcomes of surgery. But it also doesn’t carry the risks, scars, or permanency of surgery. Also, I theorize that remodeling and production of new collagen in the skin will slow the rate at which your skin sags over time, since the architecture of the skin is newer and healthier with these treatments.
Please note some of what is described above is off-label by the FDA but used routinely.
What’s best treatment for dark spots?
The best treatment for dark spots is, without question, laser treatment once the spots appear. Topical products are helpful, but most helpful in eliminating the development of brown spots. Consistent use of sunscreen and retinoids helps maintain even, bright tone, while hydroquinone specifically diminishes pigment in any area you are treating. It is reasonable to use a hydroquinone to select areas once you start to see an area of unevenness developing; I review exhaustively with my patients that if they elect to use hydroquinone, that they need to be careful with the application. If it goes outside of the area of extra pigment, there may be a whitening at the rim of the normal skin.
The best laser treatments for dark spots fall into two major categories: pigment specific lasers and fractional resurfacing lasers. Pigment specific lasers are spot treatment therapies. They are used on one spot at a time and work by selectively heating the extra pigment particles in the target area. The names of these lasers are variable, but most commonly include Ruby lasers, Yag lasers, and Alexandrite lasers. Typically, the treated areas on the face appear as tiny surface scabs for several days to a week. So planning the right time for these treatments is important, since you may have several days of looking treated, even with makeup.
“The best treatment for dark spots is, without question, laser treatment once the spots appear.”
The other category, namely fractional resurfacing lasers, primarily build collagen in the skin, but also exfoliate the surface. There are many intensities of these lasers, from ones that leave the skin pink and dry for a few hours, to one that leaves it looking superficially wounded for a week and pink for another 3-4 weeks. The stronger lasers are usually used only for patients with dramatically spotty or wrinkled skin; most patients do great with options that leave them pink and dry for a few hours and pink and dry for a few days.
The best treatment overall here is combination therapy. To achieve the optimal outcomes, I encourage all of my patients to protect their skin daily with sunscreen—even in winter and rainy days—and if their skin can tolerate it, retinol or prescription retinoids on a nightly basis. I say if they can tolerate it because the use of retinoids can make the skin irritated, but usually the skin becomes used to it, especially if the patient is moisturizing well. I use it nightly without any trouble. I then bring in the use of Ruby, Yag, and Alexandrite lasers for concentrated sun spots and fractional resurfacing lasers to diffusely exfoliate and brighten skin tone.
When my patients do this combination routinely, they are the ones people look at and say, “Wow, your skin is beautiful.”
What are the best to treat acne?
We can use blue and red lights to assist with anti-inflammatory processes of acne. But what I find more effective is integrating light and vacuum benefits in a process called photopneumatic therapy. The system brand name I use is called Isolaz. The procedure involves steaming the skin followed by a handpiece applied to the skin that can pull excess oils out of the pores. Then the system delivers an intense pulsed light that can kill acne causing bacteria as well as assist in normalizing the pink and brown acne discoloration on the skin.