There is no one device that does everything well. That really is my Commandments 1, 2 and 3. When adding laser surgery to your practice, instead of trying to do it all and being a jack-of-all-trades and a master of none (which I think is a recipe for disaster), find the one thing that you really want to treat and find the one laser that treats that thing most effectively and safely, and buy it.

My philosophy of using lasers to treat skin is to use the specific laser that is optimal for the given condition I’m treating. A single patient may be treated by three different lasers in an initial visit, if I feel that’s the optimal approach. For example, I could use one laser for treating linear veins, a different setting for diffuse redness and yet another laser for remodeling the architecture of the skin, like the wrinkles or the pore size and helping to get skin tightening. Finally, yet another laser to treat the brown spots. I do not believe the principle of purchasing one device and using it to treat all cosmetic conditions. I feel that enough things are working against you, including the biology of a patient and the difficulty of what you’re trying to accomplish, that it doesn’t pay to use anything but the absolute single optimal device for a given condition. I use only lasers and nitrogen plasma in my practice and I do not use IPLs (bright lights that are filtered in an attempt to approximate a laser).

I think IPLs are attempting to be a jack-of-all-trades and master of none, and believe that they are harder to use than lasers and less predictable in their results (despite marketing from companies to the contrary). In addition, I do not like using these devices around the eye, and think it is difficult for the laser user to protect their own eyes from these devices. This is despite them being the true market leaders. Can they be used to treat brown spots (I think they do this very well) and unwanted blood vessels?—absolutely. Are they the best choice-not in my opinion –for the above reasons. Finding the right laser surgeon also means finding one that shares the patients’ philosophy of treatment-so my method is my way and is not for everyone.

In my opinion the long-pulsed Nd:YAG laser is often sold as the laser equivalent to the IPL, billed as being able to treat all kinds of blood vessels, red ones and blue ones, able to perform skin tightening, treat scars as well as treating hair. I believe it’s quite effective for treating larger blue blood vessels in the lower extremity, however I don’t use it for that. In my office I use the long pulse YAG laser for hair removal in dark-skinned or tanned patients, and find it indispensable for this purpose.

You should never take treatment advice from sales reps, not EVER. If you do, you get what you deserve.

As a doctor you should know what/how to treat, and understand the physics of the device and the biology of what you are treating. It is extremely important to know some of the physics behind what you’re doing. Long wavelengths and large spot sizes penetrate deeply. If you’re treating a tiny spot, no matter what the wavelength, light is not going to penetrate deeply. If you are aiming at something like a tattoo or a deep blood vessel, you’re probably not going to hit it well with a tiny spot and will instead deposit most of the laser energy above your target.

In addition, one should not use large spot sizes with relatively long wavelengths (hair removal lasers) near the eye due to the risk of injuring the eye. In addition, protect the teeth during laser hair removal-these laser penetrate deeply. There is no substitute to understanding the science behind what you are doing.

I use it for treating photo-damage, every type of vascular lesion including spider veins on the face and the legs, port wine stain birthmarks, scars, rosacea and I also use it for photo-aging sun damage. I believe that the pulsed dye laser is effective for reducing pore size and tightening skin, to a limited degree, and most of my patients agree.

See Commandment #1. I do not use intense pulsed light sources in my practice because I believe:

1. It is harder to predict results with IPL
2. IPLs are not safe to use around the eye
   
3. The risk of burning the skin is greater than with lasers due to difficulty in predicting outcomes when using multiple wavelengths
4. Filtering the light so it is not too bright for the user’s eyes is difficult or impossible

The user can’t protect themselves from the light effectively enough for me, especially when there are effective and safe lasers for the various conditions in which they are used. I also never use IPLs to treat tattoos, not ever. As far as I know, it is impossible to filter these devices so that a single wavelength of light comes out at energies useful in cutaneous laser surgery as does when one uses a laser. Therefore, in my opinion, it is much harder to predict the outcome in a given patient in terms of side-effects and effectiveness.

In addition, broad-spectrum light sources are less predictable within a patient and between patients than is monochromatic light. People buy these devices to try to treat every condition with one machine or to treat a patient faster-which translates into an attempt to save money when purchasing a machine. In my opinion, this is a mistake in the aesthetic field. I believe folks should buy the device that best treats the conditions they are going to be seeing most frequently, and then add machines as their laser practice expands. In the interest of balance (ha, ha!)I would like to re-emphasize the positive-IPLs are pretty good when it comes to removing freckles without targeting the individual lesions but when painting a given area, but I don’t use them in my practice.

When treating tattoos its almost always necessary to use more than one laser. When they become resistant to one laser I believe turning it up by decreasing the spot size is more likely to cause a scar. Shrinking the spot size to increase the energy once a tattoo stops responding is in a way analogous to a bacterial infection that becomes resistant to a given antibiotic, one needs to switch the antibiotic (or in this case the laser) to a totally different machine. Tricking the spot size deposits the energy superficially which means that the laser energy is not treating the tattoo but instead is injuring the superficial skin of both the epidermis and superficial dermis and has a significant chance of making a scar.

To treat all skin types optimally, I believe, it takes more than one device and/or more than one wavelength. I use the Nd:YAG laser almost exclusively on skin types 5 and 6 and vary the pulse duration of the energy to account for the diameter of the hair and color of the skin. These parameters will change throughout a patient’s treatment history as the hair shrinks in size or the patient’s skin changes in color.

Leg veins, especially larger ones are indeed better treated with sclerotherapy than any other treatment. However, the literature supports a 15% incidence rate for matting (small clusters of bruise-resembling veins that occur as a result of sclerotherpy), and i personally think the incidence is closer to 30% (lots of folks who get matts are lost to follow-up. For these folks and those with only smaller veins (less than 0.75 mm) i think laser is a very viable option. what kind of laser? the long pulse-duration KTP used to be my favorite (versapulse, gemini); but now i use the perfecta PDL with a 40 ms pulse duration. It always requires 2-4 treatments, but folks in my practice are quite happy and i treat 4-6 people a day for this (it’s hard on the back for the doc). People with matting especially get more matting when they get further sclero, and these folks comprise 50% of the leg vein patients coming into my office. To Zac I say, “Try it, you’ll like it”. P.S.-don’t treat folks when they are tan…lighten them up first, avoid skin types IV-VI or tan folks.

Commandment #10: Most lasers exert at least 50% of their effects by causing directed inflammation…the biology of the situation is as important as the physics!

Laser Hair Removal: When the first ruby lasers for hair removal were developed, I was reluctant to offer laser hair removal because I was concerned that destroying the follicles would not be good for the skin long-term. Indeed, histology showed that a number of the follicles in treated areas were destroyed. This was not so much the case when the first highly effective and safe hair removal laser was released-the Coherent LightSheer. This diode laser was gentler on the skin. Following treatment one saw tiny hives around each follicle that contained a dark hair in the treated skin. It was obvious that this hive reaction was responsible for the hair entering a prolonged resting phase, and this seemed a safer, healthier situation to me. I then purchased a LightSheer and still use this today among the other lasers in my armamentarium.