In print ads, the "before" and "after" photographs make laser skin resurfacing-- the hot cosmetic procedure of the year--look nearly miraculous. In TV reports, demonstrations make it look like less of a hassle than remembering, day after day, to slather on Retin-A.
Could it really be this easy? Zap, zap--and kiss a few decades' worth of wrinkles goodbye?
Not quite, as even laser-wielding physicians hasten to point out. In fact, consumers are being misled, they complain. Sorry, but the so-called laser peel won't make most patients look 20 again. It's probably not as inexpensive as you've heard. And it does require recovery time, unless you're oblivious to stares and rude questions.
Even so, there are plenty of good things to say about the technique, which has skyrocketed in popularity in the last year as more doctors learn to use improved technology. At the core of their excitement: New carbon dioxide lasers that minimize the light beam's contact with tissue, giving the operator better control with less risk of thermal injury.
Quick and painless are words often used by patients and physicians to describe laser resurfacing, which can be done to the entire face or to selected areas around the eyes, mouth or chin.
On a recent Saturday morning, Valencia dermatologist Bernard Raskin took only about 10 minutes to resurface an area on the chin of Linda Martin, a Saugus office manager in her 40s who had previously undergone resurfacing around her eyes. A few minutes before Raskin began his work, an anesthetic cream was rubbed into the chin and a local anesthetic injected.
When sufficiently numb, Martin reclined, her blue eyes covered by protective cups. Raskin aimed the laser directly at the offending wrinkles, then wiped the area with a saltwater solution before aiming again, this time scanning the entire treatment area.
The resurfacing technique may remove a single cell layer of skin or much more, depending on the patient and the extent of the wrinkles. Typically, a layer about the thickness of a human hair is removed.
Like Martin, most who undergo the new technique are in their 40s or 50s; women patients outnumber men about 5 to 1. And like Nancy Kneip, 50, of Canyon Country, they aren't trying to look like teenagers again. "I wanted to look a little better for my age," says Kneip, who underwent full face resurfacing in November.
In lengthy consultations, physicians try to give patients a realistic idea of what to expect. "The deep wrinkles [you see] when raising your eyebrows and when you laugh--these are softened," explains Dr. Grant Stevens, a Marina del Rey plastic surgeon and UCLA clinical instructor of plastic surgery. But they're not eliminated, he emphasizes.
"It's not going to get rid of the deep crows' feet," agrees Dr. Bruce Achauer, an Orange plastic surgeon and director of plastic surgery at UC Irvine's Beckman Laser Institute.
For a preview: Stand expressionless in front of a mirror. The visible wrinkles are likely to be eliminated or softened. But the "lines of expression"--the ones that show up when you laugh or frown--tend to stay put because, Stevens says, "the muscles beneath the skin will continue to exert their forces."
Dr. Laurence David, a Hermosa Beach dermatologist and longtime laser expert, believes the best resurfacing results are achieved through treating the entire face, although some of his colleagues disagree. He compares resurfacing just sections to painting half a wall.
Either way, patients face a host of potential complications.
The risk of infection can be minimized by ointments, dressings and careful follow-up. Changes in skin pigmentation--either lighter or darker--are a possibility; the darker the skin, the greater the odds of such changes. And scarring can be a problem, but the likelihood of this complication tends to decrease, physicians say, as the experience of the physician increases.
Despite the brevity of the procedure, it's not "lunch hour" surgery. Immediately afterward, there may be swelling. "There is often considerable soreness the first two days after surgery," Raskin tells his patients.
Skin becomes red and then crusty. When the crust falls off, the skin is pink. "It can be four to six weeks of pink skin," Stevens says.
"We have a lot of people who won't go out of the house for a week," Achauer says. In general, doctors advise a week of recovery or isolation time.
"By the fifth day, I was out and about," says a Los Angeles resident in her mid-40s who recently underwent resurfacing. "Yes, I looked a little weird, but not that weird. By the seventh day, people thought I had a bad sunburn."
The payoff? "My face is perfectly smooth. I look 10 years younger."
Patients should avoid sun exposure for several months to minimize the risk of pigment changes, and sunscreen must be applied faithfully. Just as important as good after-care is an intensive pre-laser skin regimen in which alpha-hydroxy acids or other preparations are applied nightly.
So far, the few published studies in medical journals show little cause for concern. In a review of 47 resurfacing patients published in the journal Dermatologic Surgery, all reported redness lasting one to six months. Some also had minor complications such as dermatitis and transient pigment changes. None had scarring or permanent pigment changes.
While the laser procedure leaves skin looking sunburned, it does not carry the cancer risks of a bad sunburn, physicians and laser makers say. Sun exposure can damage the DNA within skin cells, they say, but the laser removes the cells altogether.
In another study of 61 patients, scheduled to appear in a future issue of Dermatologic Surgery, David used a new device that prevents the laser from retracing the same area, resulting in reduced treatment time. With this scanner, a full face resurfacing takes 15 minutes instead of the usual hour, he reports.
For many patients, deciding who will perform the resurfacing is the most painful part of the process. While any physician can purchase the equipment, the technique is primarily done by plastic and reconstructive surgeons, facial plastic surgeons, dermatologists and, more recently, ophthalmologists.
At the very least, a doctor should either undergo manufacturer-sponsored training or shadow an expert in the technique, observing and assisting, or both. Among the questions to ask when interviewing a physician: Where did you get your laser training? Are you board certified in your medical specialty? How many laser resurfacing procedures have you done?
"In the right hands," Stevens says, "20 to 30 might be a good number." Raskin believes a record of 25 to 50 would probably be sufficient. David, however, suggests a caseload of 250, but he concedes that probably only "five doctors in the world" have done that many.
In Southern California, prices for the procedure vary greatly, depending on the physician's location, the brand of laser used and the extent of resurfacing. Full-face resurfacing runs from about $2,000 to $4,850. Fees for selected areas such as crows' feet range from about $750 to $3,000.
Whether laser resurfacing will prove superior to chemical peels or dermabrasion--the old standbys in the wrinkle wars--is uncertain.
Some doctors contend it's a onetime procedure if patients take care of their skin. But Stevens believes that promise is premature. Given the brief history of the technique, he says, "It's hard to say this is permanent."