OT: the laser turns 50

It's 50 years old (as of Sunday, May 16, 2010) - and still just as cool as ever.

The first laser was fired up 50 years ago, by a clever researcher named Theodore Maiman, at the Hughes research labs (now Raytheon) in California. Despite getting a laser working first, Maiman didn't get his name on the patent for the laser - that went to Charles Townes, who had been also working on the project over at Bell Labs, and was the inventor of the "maser" - microwave laser, if you will - and who had previously described how the maser could be adapted to work with visible light. Townes later shared a Nobel Prize in Physics for his contributions to the development of the laser.

Today, the laser is ubiquitous - whether it's in the price scanner at the grocery store, your DVD & CD player, your fibreoptic communications networks, laser printer, or a rock and roll light show, it's mainstream technology.

In our plastic surgery office, lasers play a helpful medical role, zapping veins, removing unwanted hair, and resurfacing skin.

Even Albert Einstein, who first conceived of the theoretical possibility of lasers and masers back in 1917, would be amazed!

Cool stuff! Laser assisted microsurgery

When plastic surgeons move tissue from one area of the body to another using the "free flap" technique, the crucial stage is the hook-up of tiny arteries and veins, so that the moved tissue can receive blood and oxygen in its new location. Since the 1960's, this has been done with micro-sutures, sewing the vessels together with the aid of an operating microscope. It's quite difficult, and the success of the surgery really depends on the skill of the surgeon, using sutures smaller than a human hair.

In this month's issue of Plastic and Reconstructive Surgery, a new report from France discusses laser welding of these tiny vessels. Once the tiny arteries and veins are lined up, a small low-power diode laser has been used successfully to join the vessels together, like a high-tech pipe fitter welding two pipes together.

In the French study, 27 patients had reconstructive microsurgery using the laser diode welding technique on 58 vessels, ranging between 0.8 to 1.8 millimeters in diameter. Patency of the laser-welded vessels was excellent, at 96.6%. And the new technique was quicker, reducing overall surgery time and "ischemic" time - the critical time between the separation and the reconnection of the blood vessels to the moved tissue.

Impression: This looks like it could be a winner for microsurgery. The next step will be some direct comparison studies between laser, traditional suture techniques and the mechanical vessel coupler device. In addition, the use of the low-power laser could potentially be adopted for use in laparoscopic surgery, for biliary or urinary tract surgery. Time will tell.

A new laser treatment for stretch marks? Maybe.

When patients come in with stretch marks, we've traditionally had little to offer them. Retin-A cream helps somewhat. IPL and vascular lasers can be used if the stretch marks are red or purple in color. But that was about it, unless the stretch marks were on the lower portion of the abdomen - and the patient wanted a tummy tuck, which would surgically remove the entire zone of stretch-mark laden skin.

Well, guess what. Just this month, Palomar Medical Technologies announced that their Lux1540 laser handpiece has received clearance by the FDA for the treatment of stretch marks. As you might expect, the company, their accountants and their stockholders are all very excited about this, as now they can market this laser to the millions of women worldwide who have unwanted stretch marks.

As we've discussed before, FDA approval for devices doesn't necessarily imply that the gadget is effective - just that it is reasonably safe. So does this laser really do what it claims?

The Lux 1540 isn't that new - it's a fractional, non-ablative "erbium-glass" laser that's been previously used for skin resurfacing and the treatment of scars. What's new here is the official indication for use in stretch mark therapy. According to the data submitted to the FDA, clinical studies with the Lux1540 achieved an average improvement of between 51% and 75% in the appearance of stretch marks, over a three month time period. Of course, that's corporate-sponsored research. I haven't seen any peer-reviewed, independent studies as yet.

So, the stretch marks got better with the treatment, but did not vanish. Nevertheless, this could represent an improvement over the previous non-surgical therapies we've had for striae....we'll have to see how it pans out in independent trials.

Bottom line: cautiously optimistic.

Problems with laser-liposuction: who's the Smart one now?

Over the last few months, I have seen an alarming increase in the number of patients that come in for a second opinion about poorly-performed liposuction (done elsewhere, I might add.) All of these casse have been performed with new high-tech liposuction machines, either laser-assisted (like the SmartLipo) or ultrasonic (like the VASER).

I've seen major skin laxity, uneven liposuction, and obvious over-resection of fat leaving major divots and dents. Many of these problems are very difficult to fix, even with fat grafting techniques.

Here's a few observations:

1. All of these cases were performed by physicians and surgeons operating way outside of their specialty. They were not done by plastic surgeons or dermatologists, who are trained during residency in this technique.

2. In the majority of these patients, physical examination of the patient revealed crummy skin tone and poorly elasticized skin. In other words, since this skin won't contract like we want it to after liposuction, it's completely predictable that the post-op results will be poor, with floppy, deflated areas, and a worsened appearance. A surgeon with any significant training or experience in liposuction would have recognized this - and would have avoided performing liposuction in these patients. It's the wrong tool for the job!

3. All of these patients were preoperatively told by their physicians, "This new wonder lipo machine will tighten your skin".

4. All of these patients now say, "Skin tightening clearly did not happen...now I look worse."

5. None of these patients have an easy fix for their issues. All will require complex and expensive revisional surgery.

Lessons:

A fancy hammer does not a good carpenter make. Any doctor can buy (or rent) a fancy lipo machine.

There is, as yet, no reliable scientific evidence that laser-assisted liposuction:
a) tightens the skin, or
b) works better than standard liposuction.
Any claims to the contrary are "spin" or marketing hype; consider the source and what they're selling.

That being said, the problems seen here were not caused by the type of liposuction machine - but by the doofus using it! While the concept of liposuction is easy, getting excellent results with liposuction takes significant skill.

Please be careful about whom you choose to perform your liposuction. Even if it's performed in an office setting, with local anesthesia, liposuction surgery is still SURGERY. Training, experience and credentials matter.

Fractional CO2 laser resurfacing

Every so often, a significant breakthrough comes along in Plastic Surgery - and this, I believe, is one of them. It's a new twist on a familiar theme. In this case, the new twist is a gadget called a "fractional laser scanner". This is an optical-mechanical device that manipulates an incoming laser beam, creating a polka-dot pattern of laser dots. Normal, untreated skin is left in-between the treated / lasered areas, rather than zapping the entire surface of the skin.

Since only a small fraction of the skin is treated, the technique is known as fractional resurfacing. It can be thought of as a kindler, gentler way to do skin resurfacing. It's not as dramatic a result as the traditional CO2 laser - but the recovery is also far, far easier. The down-time is about 3-7 days, with very little pain. I've been using a european machine, called the Ellipse Juvia, for my treatments since march 2007. (I believe we had the first Juvia unit in the entire South-East.) While laser resurfacing is not a replacement for a facelift, it does a nice job improving texture problems, fine wrinkles and clearing up sun damage.


There are about a dozen machines out there that use this fractional co2 laser technology - and to be honest, they are all fairly similar, whether they are called "Active FX", "DOT therapy", "mixto" or "Juvia". What's confusing for the consumer, however, is that the original "Fraxel" machine - isn't a CO2 laser. It uses a different, less powerful wavelength - so the results with the original Fraxel have not been as impressive.

There are also 2 machines - the Fraxel Repair and the Deep FX - that are designed for deeper treatments. The jury is still out on these...as the complication rate may be higher, and as yet, the treatment parameters have not been optimized.

If you decide to have this treatment done, make sure you go to a physician with plenty of CO2 laser experience. While fractional treatments can be done very lightly, all of these machines can be turned up to give a very intense treatment. They are by no means "goof-proof". Experience of the laser operator is the key to a good result.