Light Years

November 2006

The shadowy divot above my left eyebrow came, ironically, from a dermatologist’s attempt to “clean out” a patch of stubborn adolescent acne. For almost 20 years since, I’ve wished I’d told the man in the lab coat to leave the spots alone, a sentiment I expressed casually to my husband one night at our favorite restaurant. His response was disheartening. “You can barely see it,” he said. “It blends in with the lines.”

The lines? As he backpedaled frantically, I whipped out a mirror to inspect my 33-year-old forehead. The pale crater was, indeed, bisected by a few wispy lines. “The light’s really bad in here,” my husband mumbled quietly.

The call from my editor came later that week, and not a moment too soon. She was planning a story on dermatologic lasers, lights, and energy sources, a burgeoning class of devices that promise to zap away hair and uneven pigmentation, wrinkles, fat, and veins—and, some fast-talking doctors claim, erase a decade’s worth of sun damage in a single lunch hour. With new attention being paid to off-face areas (because age spots and sagging don’t discriminate), these gadgets keep evolving to take on the contours of the hands, the thin- skinned décolleté, and everywhere in between. But there is so much new technology, it’s hard to get a handle on what works—and for where.

Determined to slog through the alphabet soup, I hop a cab to Neil Sadick, M.D.,’s gleaming new Park Avenue office (or, more accurately, dermatology supercenter). Sadick, a clinical professor of dermatology at Cornell University Medical College who often runs clinical trials for the FDA, moved in earlier this year when his arsenal of lasers and energy devices began overtaking his old digs like something out of a sci-fi movie. Here, the look is still very Battlestar Galactica, but it’s also pleasantly airy and spare. The machines in question are cleverly concealed behind sliding doors in each treatment room, so as not to “frighten” the clientele. Adam Dinkes, chief operating officer of Sadick Dermatology Center, describes their appearance as “R2-D2” with their blinking lights and whirring noises. The one stylish touch dangling off each: a pair of oversize, Dior-esque safety goggles. Sadick glows when showing off his Vectra 3D supercamera, whose eight lenses document even the most minute changes in patients’ skin texture, pore size, pigment, translucency, and facial contours. Conservatively speaking, there is more than $2.5 million in technology behind these Park Avenue doors.

Sadick first started tinkering with Intense Pulsed Light (IPL) back in the late eighties as a treatment for leg veins and noticed it left the skin smoother. These days, IPL is one of the most popular devices for smoothing red and brown blotches on the face, chest, and hands—and can put acne into remission for about six months. The Pulsed Dye Laser—which debuted nearly 20 years ago as a treatment for red port-wine-stain birthmarks—is now the weapon of choice of Jeffrey Dover, M.D., associate clinical professor of dermatology at Yale University School of Medicine, for treating facial redness and dilated red blood vessels over the entire body. And doctors have long banished individual brown spots on the face, chest, and hands in a single shot with the Nd:YAG. Several years after the FDA approved photodynamic therapy (PDT)—which uses a topical acid called Levulan to maximize laser absorption—for skin cancer treatment, dermatologists discovered that it, too, had potential for sun spots and acne.

Even the mighty carbon dioxide (CO,) laser, which was heralded and then feared in the nineties for its resurfacing blowtorch effect on the skin, still makes cameo appearances in some offices. One treatment takes care of lines, spots, scars, and blemishes, getting you as close to perfect as you can without a magic wand—if you don’t mind the crusting, oozing, and a week or two of post-op seclusion. (These days, doctors wield it less aggressively to minimize the risk of scarring, potential changes in pigment, and recovery time.)

Sitting at his sleek, marble-topped desk, Sadick explains that few of his busy, well-heeled patients have the time, or the stomach, for ablative (i.e., surface-wounding) anti-aging treatments like the CO2. In many cases they’re “willing to settle for less effective results and multiple treatments” in exchange for the freedom to leave home the next day. True, the results unfold gradually, but that’s the beauty of it, says Sadick: “People don’t necessarily want to look a decade younger anymore. They just want to look better and fresher. That’s why there’s such a boom in the noninvasive, non-ablative world.”

I’m all for better, fresher, and gradual, but if I spent upward of $5,000—and many precious hours—on a round of treatments, I’d want to see meaningful change. And not just with a high-resolution supercam. Sadick admits that until recently, much of the non-ablative anti-wrinkling technology was something of a black box. Collagen-stimulating lasers like the CoolTouch, Polaris, and Smooth- Beam, which use heat to even texture and reduce wrinkles, do wonders for some—and squat for others. “I’d say about 25 to 33 percent have an excellent response,” says Sadick. “Maybe 50 to 60 percent have some improvement that makes them happy, and then there are 20 to 30 percent who don’t have enough of a response for either themselves or the physician.” Surely there must be a way to predict who will go home disappointed? Not really, Sadick answers. For whatever reason, some women’s collagen is more resistant than others’.
For a time, Thermage’s track record was even sketchier. This deep-heating radio-frequency device was touted four years ago as a scalpel-less alternative to plastic surgery: a way to tighten the inevitable sagging and crepiness that creeps in around the mid-40s to 50s. “But it turns out it was really slow, very tedious, and very painful,” says Dover. “Only 30 percent of patients saw improvement, which meant that 70 percent did not.” What a difference a few years makes. After a much-needed extreme makeover, Thermage is back with larger hand pieces to cover wide swaths of skin more quickly and less torturously, and smaller ones to lift and firm the delicate eye area. (The lower face and neck are still the most responsive to the treatment.) Technique has changed, too: Most doctors use several lower-energy passes rather than a single high-energy shot, which cuts down on pain…though not usually enough to eliminate the need for Percocet or Valium beforehand. In a recent study of fourteen laser centers around the world, including Dover’s, 94 percent of 5,700 patients were satisfied with their results.

And suddenly, those looking to firm jiggling jawlines have other options as well The Titan employs a broad-spectrum infrared lamp to deliver heat—almost painlessly—to the deepest layers of the skin. (Sadick is even treating some patients’ arms, thighs, and postpartum bellies.) The eMax delivers a one-two punch of radio frequency and laser. Dover is optimistic about the new Palomar LuxIR, which pulses a checkerboard of tiny infrared beams, leaving squares of flesh untouched. Theoretically, this allows collagen tissue to repair and regenerate at lightning speed—and virtually eliminates downtime. Dover suspects that patients may need more than one treatment with these new devices to achieve the results of one round of Thermage, but no one’s tested his theory yet.

Dover’s voice modulates up excitedly when he mentions the checkerboard concept. So-called fractional procedures are the talk of dermatology conventions these days because they may offer the ultimate marriage between the ablative and non-ablative worlds. Sadick dubs them microablative. The most hyped of these is the Fraxel laser. Like the LuxIR, it creates a lattice of micro-wounds next to untouched skin. But rather than tightening deep below the surface, it works more on the upper layers of the skin.

When it started appearing in doctors’ offices last year, tantalizing rumors circulated that five Fraxel sessions worked as well as one harrowing CO2 treatment— and wouldn’t leave you looking like the Bride of Frankenstein for a week. Enthusiasm has since cooled a bit. While Sadick remains a fan, he concedes that “the results in terms of wrinkle reduction have been a little disappointing” Rhoda Narins, M.D., president of the American Society for Dermatologic Surgery, prefers the “home run” of the CC),, especially since the advent of gentler, lower-energy techniques.

So why is there still so much fuss about Fraxel? What is it good for? Early fine lines, diffused pigmentation, and acne scarring. Most doctors consider it a very acceptable alternative to CC), resurfacing for treating darker complexions (which can permanently lose pigment during ablative procedures); for all skin types, it’s a popular tool for delicate areas like the neck, chest, and hands.

The newest kids on the block are the Sciton and Portrait plasma devices. The former is a new generation of erbium laser (that trusted class of ablative devices known for being almost as effective, but not quite as wounding, as the C02). The latter uses high-energy nitrogen gas to heat and resurface the skin, leaving behind a paper-thin crust that acts as a protective dressing. “Once it falls off,” says Dover, “you have fresh, beautiful skin underneath.” Both the Sciton and Portrait tackle wrinkles, and both let patients decide just how aggressive they want to go. Lower-energy treatments might sideline you for only three days, but you’ll need several sessions to equal the results of one high-energy round. Assuming you opt for more juice, notes Tina Alster, M.D., of the Washington Institute of Dermatologic Laser Surgery in Washington, DC, these machines do more than the Fraxel, treatment for treatment. But they come with a week of recovery time, which is why “my patients all prefer Fraxel,” she says.

In the past, lasers aimed at permanent hair removal—which targeted melanin in the skin and hair—were effective only on women with fair skin and dark fuzz, eliminating women with light hair or dark skin. For those in the first category, the new eLaser delivers an “inside-out attack,” says Sadick. Its laser component damages the offending hair; radio frequency causes heat damage to the follicles. Blondes require five to ten treatments (as opposed to three to five for brunettes). For darker complexions, Alster says, Nd:YAG lasers, like the Gemini, are effective over five to eight treatments.

Sadick is the first to admit that fat-targeting lasers and energy sources are still in their infancy, but they’re growing up fast. The VelaSmooth recontours puckers with a three-pronged dose of heat, radio frequency, and massage. While Sadick calls the device “innovative,” he says it’s hardly a miracle worker. Dover has his eye on the UltraShape Contour (an Israeli gadget that maybe available in the United States within the next year), which “uses focused ultrasound to melt fat. A single treatment can reduce waist circumference by an inch, but it takes two hours and it’s tedious,” he says. Other companies are playing with the ultrasound concept, along with fat-targeting shock waves and electrical stimulation. (In August, the FDA approved Med Sculpt, which combines ultrasound with vacuum massage.)

Stretch marks—famously resistant to all manner of treatment—have also joined the hit list. The new MultiClear sends out beams of UV light to stimulate melanin production and repigment chalky white surface marks. For depressed marks, Sadick adds a few sessions with Fraxel— but admits the results are unpredictable. As with snowflakes, no two stretch marks are alike, says Alster. While some melt away rather easily, others do not.

As for me and my divot (along with the recently discovered road map on my forehead), Sadick recommends Fraxel “to remodel” the skin. Improvement won’t he obvious immediately, he says, since most of the collagen building occurs during the weeks following each treatment.

So I sign a flurry of worst-case-scenario release forms (I understand that this is a new treatment with risks of permanent scarring, blah, blah, blah) and take a seat while the Vectra 3D documents every imperfection on my face. A physician’s assistant named Judy coats my face with topical anesthetic, then with the Smurf-blue dye that will absorb the beams she’s about to pulse into my skin. “How much will this hurt?” I ask. “It’s no worse than holding a hot hair dryer too close to your skin,” she says. By the next day, the flushing is barely noticeable. Judy calls later that week. I tell her that my forehead and cheeks (where I have additional scarring), while not perfect, already look better. (A few weeks later, the depressions on my temples have smoothed considerably; even the lines have faded slightly.) What I don’t tell her is that this rather instant improvement has made me shift my focus to the lines around my eyes and mouth. No wonder so many people are so enthusiastically signing up for these treatments—services that seem more akin to highlight touch-ups than the traditional surgical procedures they’re replacing. You might call it an addiction. Or basic maintenance.