During the past few years, development of medical lasers has advanced at an extremely rapid pace. Aside from the effects on skin and related structures, the medical uses of lasers encompass applications in a wide variety of specialties, including not only dermatology and plastic surgery, but also gynecology, neurosurgery, orthopedic and cardiovascular surgery. A great deal of attention is currently being focused on the effects of the laser in ophthalmology, both to repair damage of the retina and also to eliminate the need for eyeglasses.

The use of lasers in plastic surgery and dermatology derives from the ability to utilize a specific laser wavelength, energy level, and duration of exposure to accomplish the purpose intended, enabling the laser surgeon to perform a wide variety of procedures. These include operating through a small incision in the skin to perform endoscopic brow and face lifts, thereby minimizing the amount of cutting necessary to perform these procedures. Resurfacing of sun damaged and wrinkled skin eliminates unwanted lines of the face, especially around the eyes and mouth. Other lasers assist in hair transplantation, removal of unwanted hair of the face and body, destruction of facial blood vessels and small varicose veins and capillaries of the legs, and destroying pigmented lesions of the skin, such as tattoos and freckles. Each of these uses will be described in greater detail below.

Skin Resurafacing and Reconditioning: Advances in understanding biophysics, optics, molecular biology, and chemistry of the skin have given physicians powerful new tools to rejuvenate skin and correct facial scarring. These tools include lasers, chemical peels, botox, collagen and filler substances. Often, a combination of these various techniques will enable the plastic surgeon or dermatologist to offer his or her patients dramatic therapeutic results.

Skin aging is caused primarily by sun exposure, which destroys elastic tissue, resulting in loose, wrinkled and discolored skin. Facial resurfacing is performed using either a carbon dioxide laser or an erbium Yag laser. The erbium laser produces a more superficial effect on skin than the carbon dioxide laser, enabling quicker recovery, but also less dramatic and shorter lasting improvement. Superpulsed and ultrapulsed carbon dioxide laser systems produce a greater improvement, but also require a much longer recovery period. Careful preparation of the skin for several weeks prior to resurfacing is necessary for the best possible outcome of both laser resurfacing and facial peels. This includes topical application of retinoic or alpha-hydroxy acids to the skin.

If the patient has considerable freckling or sunspots, or has somewhat darker skin, hydroquinone or other bleaching agents are used. It is important for the surgeon to take a complete medical history to exclude problems of excessive scar formation, bleeding problems, delayed healing or susceptibility to infection, and history of herpes simplex breakouts. If the patient has used Accutane, the drug should have been discontinued for at least one year before the resurfacing procedure. Otherwise, there is increased risk of significant permanent scar formation. Potential complications of laser resurfacing may include changes in skin pigmentation, especially in patients with dark Mediterranean, Asian, or Afro-American skin. In these dark-skinned patients, hyperpigmentation, or darkening of the skin may develop following laser resurfacing, and last for several months or longer. Generally, this hyperpigmentation can be successfully treated with the use of bleaching agents, but this may take considerable time to resolve. Resurfacing the neck and the area of the skin overlying the jawbone has a greater chance of producing significant scars than the rest of the face. Additionally, laser resurfacing of the hands also carries with it an increased risk of scaring.

Other complications have included delayed healing and persistent abscess formation, but are fortunately quite rare. In order to minimize the risk of complications, it is extremely important for the patient to see the operating surgeon at frequent intervals during at least a two week post operative period, since careful immediate post-operative care is essential for satisfactory healing. In most cases, a single laser resurfacing will produce between a fifty and seventy-five percent improvement in facial skin appearance. Some patients may require a second procedure performed several months later for maximum benefit. Redness of the face can persist for up to six months after the procedure, requiring careful protection against sun exposure, including the use of a good sunscreen, and wearing a hat during sunny weather.

In addition to the erbium laser, other new lasers have been introduced, including the Cool Touch, which produces prompt improvement with minimal recovery times. However, the improvement from these new lasers is less striking, and can often be matched by other techniques such as skin peeling.

Removal of tattoos and pigmented lesions, such as sunspots and freckles, respond well to a variety of lasers and intense pulse light therapy. However, any laser treatment may produce a scab or a black and blue mark, persisting for nine days up to two weeks. Multicolored tattoos, containing both blue and green pigmentation may require the use of two different lasers to eliminate all the colors. Professionally applied tattoos, especially those with black and darker colors, require several sessions based weeks to months apart for satisfactory removal of these lesions.

Additionally, a laser-like technology, called intense pulse light therapy, which uses visible light with a filter cutting out light beyond certain wavelengths, has been reported to be very effective for removal of blood vessels of the face and legs, as well as other pigmented lesions. Most recently, intense pulse light therapy has been used for photo-rejuvenation of the skin. Early results seem to be very impressive, as technology is too new to have longstanding and widespread follow-up.

In brief, the choice of laser must be left to the treating physician, and the most important factor in successful outcome of laser treatment is careful follow-up by a well trained laser surgeon. To avoid disappointment, it is very important to discuss possible risks and benefits prior to treatment. Any laser treatment does carry with it a small risk of unwanted pigmentary changes and scar formation, although these complications are infrequent.