DrH's Laser Device Guide

Importance of Laser Device Choice

There are two key ingredients for successful outcomes in any laser procedure:

1. Skill and experience of the operator
2. The best device for the procedure in question

Laser in skin surgery is a complex area. It is also one that is not highly understood by many doctors, dermatologists and plastic surgeons in the UK. Due to macroeconomic issues and lack of NHS funding most NHS trained Dermatologists and Plastic Surgeons lack sufficient knowledge and experience of laser use as they were not exposed to the devices or did not receive any practical training with these devices in their NHS training.

Laser devices are becoming rapidly more available for medical and aesthetic treatment in the private sector. Unfortunately lack of training for dermatologists and plastic surgeons in the NHS and lack of lasers in the NHS leads to a lack of medical professionals highly trained in the use of these devices. It is not surprising that due to the plethora of devices, the complexity of light-tissue interaction and lack of medical professional training laser skin treatment is a very high-risk practice area in the UK.

DrH is a globally renowned expert and fully understands the complexity of skin laser surgery. This has been his specialist interest and has formed his daily workload over the past decade. This means that his degree of practical expertise and experience cannot be matched. Performing thousands of laser cases over the last decade gives him experience over and above any other UK dermatologist or plastic surgeon. You can be sure you are in skilled and experienced hands when it comes to being treated by DrH.

DrH also insists on choosing the best device for the job. Although he is a key opinion leader for laser manufacturers, he will only use the best-in-class device for treatment. This is important as devices can limit the success of laser treatment. As DrH funds his own devices his fleet of lasers he will only incorporate the best-in-class device for each category.

Vascular Lasers

Used in the treatment of:

• Rosacea
• Facial Thread Veins
• Leg Veins (Telangiectasia and Reticular Veins)
• Generalised redness
• Port Wine Stain Birthmarks
• Spider Naevi
• Cherry Angiomas
• Eye (periorbital) Veins
• Venous Lakes
• Ateriovenous Malformations AVMs
• Hereditary Haemorrhagic Telangiectasia

There is a myriad of options when it comes to treating veins and blood vessels with laser. These are as follows:

• Intense Pulsed Light devices e.g. Lumenis M22 , Sciton BBL , Cutera Xeo
• Pulsed Dye Lasers (PDL/NdYAG) eg. Candela Vbeam Prima / Cynosure Cynergy
• KTP/NdYAG Lasers (Potassium Titanyl Phosphate) / LBO (Lithium Triborate)

In general, many clinics will treat with IPL devices. These are actually NOT lasers. They use a powerful light source to which specific filters are applied to simulate particular laser wavelengths. Many aesthetic clinics prefer these devices as they are cheaper and multipurpose depending on which filters are attached. Certain treatments can be performed with reasonable efficacy with an IPL device. However, they are still a non-specialist tool when it comes to treating vascular problems like those listed above.

Ultrapulse Alpha Laser

Experts in the treatment of skin vascular issues prefer a specific vascular laser such as a PDL/NdYAG Combined Laser (Candela V beam Prima or Cynosure Cynergy) or a Combined KTP/NdYAG laser. The reason for this is because of the fact that they use monochromatic light and have high power output. These devices often have an NdYAG laser combined for treatment of larger blood vessels and thicker vascular lesions. Essentially these are lasers that are specifically designed for treatment of vascular problems (Hence the ‘V’ often in the name of the device).

Pulse Dye Lasers such as the Candela V beam Prima, Candela V beam Perfecta use a special dye to produce yellow laser light of wavelength 585-595nm. This is a wavelength that is well absorbed by oxygenated blood making it a good laser for the treatment of rosacea, generalised redness, spider naevi etc. Theoretically green laser light would be a better and more effective choice for blood vessels. However Pulsed Dye Laser was the gold standard for vascular lasers until 2010. This was because until then KTP crystal technology did not allow for green light laser beam to be produced at an adequate size and power to make it practical to treat large surface areas of skin. The first medical vascular green light lasers only had a spot size of around 2mm in diameter. This small beam made it virtually impossible to treat larger areas. They were however useful for tracing out individual small veins and blood vessels.

Finally advances in optics allowed for green light lasers of sufficient power output and stability to be developed that would allow them to produce beams large enough to make treatment of common conditions such as rosacea much more practical. These were the next generation of devices that became the gold standard. Combination KTP./NdYAG laser technology was pioneered in the Cutera Excel V. It still today is mainstay laser for vascular specialists and allows for superior efficacy over the PDL/NdYAG lasers that preceded it.

The latest generation of vascular laser has taken the KTP/NdYAG laser device forwards. The wavelengths are the same but the game changing device that has revolutionised vascular treatments is the Lutronic DermaV. This uses the same wavelength combination of KTP/NdYAG as the Cutera Excel V however the Lutronic DermaV can deliver laser energy in microsecond stacked pulses. This evolution in technology allows for tougher smaller calibre blood vessels to be treated. Effectively where the previous generation of KTP/NdYAG laser would reach its maximum efficacy would result in a level of improvement that would be capped. The microsecond stacked pulse KTP/NdYAG lasers can further reduce previously untreatable small calibre vessels giving greater improvement and clearance in conditions such as rosacea, generalised redness, port wine stains.

Sometimes manufacturers of PDL lasers will try to argue that due to longer wavelength penetration is better and it is safer on darker skin types. On the contrary the depth of penetration advantage is negligible and is easily overcome by increasing spot size in the superior KTP/NdYAG lasers. Contrary to popular belief the KTP lasers are also safer on darker skin types as the KTP 532nm wavelength is more highly absorbed by blood vessels. This means that lower energy is required to achieve the same outcome versus a 595nm PDL. As a result, there is less of a risk of adverse consequences such as bruising and post inflammatory hyperpigmentation. Moreover, for the users of PDL the dye kit within the laser is a costly maintenance issue. There have been many problems with the supply of Dye kits over the years leading to prolonged periods of inactivity of these lasers. The Candela V beam Prima was plagued by reliability issues and has since been withdrawn from the market. The Candela V beam perfecta is the older model that is still currently available but unfortunately has no NdYAG module. Essentially, I would not recommend the purchase of a Pulse Dye Laser. It is rapidly becoming redundant and outdated. 532nm solid state crystal-based technology makes for a much better alternative with much less in maintenance costs due to the elimination of need for dye kits.

In summary the KTP/Nd YAG combination laser and its latest microsecond pulsed generation makes for the best-in-class device for the treatment of blood vessels.

This is why DrH still uses Cutera Excel V and has acquired the all new Lutronic Derma V.

The Lutronic Derma V is now the most powerful and versatile vascular laser on the market.

CO2 and Erbium YAG ABLATIVE Resurfacing Lasers

Used in the treatment of:

• Moderate to Severe Acne Scars
• skin Lesion Removal
• Incisional Skin surgery
• Rhinophyma Surgery
• Xanthelasma removal
• mole removal
• Moderate to Severe Sundamage and Precancerous lesion removal

These lasers are used by skin laser surgeons for the treatment of the above skin conditions.

CO2 lasers and Erbium YAG lasers are used to remove layers of skin tissue or abnormal skin tissue. This is called ablative skin laser surgery. These lasers effectively vaporise the skin cells they are fired at essentially turning the skin into gas and particulate matter. This allows for very precise removal of skin tissue. The precision and degree of control offered by these types of laser allow for minimal damage to normal tissue. This therefore allows precise and controlled wounding of the skin to micrometric accuracy and minimisation of collateral damage. These properties make CO2 and Erbium YAG lasers a very versatile tool in skin surgery.

CO2 and Erbium YAG Lasers can be used in FULL ABLATION mode which is required for procedures such as:

• Fully ablative skin resurfacing in aggressive acne scar management
• Fully ablative skin resurfacing for extensive sun damage, deep wrinkles around the eyes and mouth
• Rhinophyma surgery
• Xanthelasma removal
• Skin lesion removal such as laser mole removal

CO2 and Erbium YAG Lasers can be used in FRACTIONAL mode which is required for procedures such as:

• Keloid Scar Treatment
• Burns Contracture Release
• Atrophic Acne Scar treatment
• Surgical Scar and Traumatic Scar Remodelling
• Laser Assisted Drug Delivery

Which is more effective CO2 or Erbium YAG?

The answer to this question is that it depends on what you are treating. The right tool is required for the right job. In debulking rhinophyma surgery where more heat is required for coagulation and prevention of bleeding a CO2 laser may be the natural choice. In cosmetic mole removal where minimal collateral damage is required to produce minimal scarring the relatively finer and colder ablation of an Erbium YAG laser makes it the tool of preference. Xanthelasma surgery around the eye requires a more delicate approach hence Erbium YAG laser confers a better result. The overall outcome is also highly dependent on the skill and experience of the surgeon.

In acne scar treatment full ablation CO2 allows for greater ablative and thermal coagulative remodelling of the dermis. However, there is a limitation in depth. The deeper the scars the more useful an Erbium YAG laser becomes as it is with the colder ablation of Erbium YAG laser that we can penetrate into the deeper layers of the dermis. The answer here is once again both lasers are required depending on the case being treated.

This is why DrH carries the LUMENIS ULTRAPULSE ALPHA CO2 and SCITON JOULE X Erbium YAG laser. It is well known in the laser specialist community that both these devices are the most powerful and versatile skin ablative lasers in their respective classes.

Mid-range CO2 lasers that are suitable for lighter atrophic acne scarring (fractional ablation) and laser incisional skin surgery such as laser blepharoplasty are devices such as the DEKA SmartXide PRO or the Lumenis Accupulse. The pulse width limitations make these CO2 lasers unsuitable for fully ablative skin resurfacing. However, they can be used for more aggressive fractional ablative resurfacing for acne scarring. The pulsewidth and power output of these devices do not allow them to be suitable for specialist scar treatment such as contracture release for burns scars or scar tension release / laser assisted drug delivery in keloid and hypertrophic scars. Fractional Laser Assisted Drug Delivery in administration of topical photosensitising agents in the treatment of precancerous lesions (a method of enhancing photodynamic therapy PDT) is also a technique that these types of laser can be used to provide. As a result they are excellent tools for specific types of skin surgery and most regular minor laser skin surgery. They make useful tools when used at lower power output for intradermal laser assisted drug delivery. These lasers can also be used for assisting in transepidermal pigment removal when used in conjunction with picosecond lasers to reduce resistant tattoos. Unfortunately these devices lack the power output, short pulse widths and energy delivery mechanisms that are required for specialists in acne scar management, scar management, fully ablative skin resurfacing and burns surgery. Low level superficial scar remodelling for surgical or traumatic scars can be achieved by these devices.

Better results with surgical scar/traumatic scar remodelling and burns contracture release require High-Energy Low-Density CO2 (abbreviated as Fractional H.E.L.D. CO2) that is only capable of being delivered by the Lumenis Ultrapulse ENCORE or its newest variant the Lumenis Ultrapulse ALPHA.

There are more specialist surgical CO2 lasers for areas of surgery such as ENT (eg DEKA SmartXide2 Trio) but these are out of the scope of this section,

In the more basic CO2 category, there are several lower power output devices which can be more suited to aesthetic / cosmetic fractional skin resurfacing skin resurfacing. These are devices such as the Candela CO2RE CO2. These devices are appropriate for lighter fractional cosmetic skin resurfacing, Lack of power output and energy delivery mechanisms make them completely unsuitable for fully ablative laser resurfacing and High Energy Low Density Fractional CO2 treatment for traumatic and operative scar remodelling. They also have inadequate penetration depth for treatment of Keloid and Hypertrophic Scars.

In the Erbium YAG category the power output of the Sciton Erbium YAG makes it a suitable tool for deep fully ablative skin resurfacing. It is also a tuneable Erbium YAG laser in which additional energy delivery can be modulated to simulate the coagulative properties of CO2 laser. The power output and the coagulative tunability make the Sciton Joule X Erbium YAG the most powerful and versatile Erbium YAG laser in its class, Sciton are also able to customise the Joule X laser to incorporate 2 Erbium YAG modules for greater power, speed and versatility in advanced full ablative. Naturally DrH opted for a customised Sciton Joule X dual Erbium YAG as his Erbium YAG laser of choice.

Fotona also make an excellent Erbium YAG laser. The Fotona SP Dynamis is an excellent device for experienced skin surgeons who want an excellent quality reliable Erbium YAG for their skin surgery. The build quality, reliability and handpiece quality are excellent. The cost is much more affordable versus a Sciton Joule X

For the few surgeons worldwide, that specialise in full ablation resurfacing the Sciton Joule X has handpieces, scanners, power output and tuneable energy delivery mechanisms that make it a far more superior tool to the Fotona for this niche speciality area.

An excellent and high quality entry level Erbium YAG laser that is suitable for dermatologists or plastic surgeons who are relatively new to skin laser surgery should consider the Asclepion MCL Dermablate. It is an affordable and high quality Erbium YAG laser that is suitable for minor skin laser surgery and lesion removal. Its handpieces do enable fractional skin resurfacing however for this procedure it is not at all the optimal tool.

Picosecond Pigment Lasers (skin lesions and melanin VS Tattoo Removal)

DrH specialises in skin surgery and involves treating many patients with darker skin types. Management of pigmented lesions within his practice essentially involves management of the following skin conditions:

• post inflammatory hyperpigmentation PIH
• treatment of sundamage pigmentation (sunspots/age spots/solar lentigines)
• melasma
• management of pigmented birthmarks (Café Au Lait Macules / Naevus of Becker / Naevus Spilus / Epidermal Naevi / Congenital Melanocytic Naevi / Naevus of Ota )

Because of the variable density and depth of melaning within the skin compounded by the ratio of lesional melanin versus normal melanin in darker skin types there is only one device that is suitable for management of the above skin conditions in all skin types. This is the Cynosure Picosure Pro Laser. It is unique as due to its use of 755nm wavelength and picosecond pulsewidth the laser skin surgeon can treat both superficial and deep melanotic lesions in patients of all skin types. This laser and wavelength also permits for the degree of control of energy delivery required for management of pigmented lesions and disorders of pigmentation in darker skin types.

Does this mean that it is the ideal laser for all pigment issues. Whilst it can be used quite effectively for removal of tattoos it is not necessarily the best device for tattoo removal. The Cynosure Picosure Pro emits a 755nm Alexandrite Wavelength at 750-550ps pulsewidth. It has a 0.8GW peak power output. Essentially it is without equal for superficial and deep pigmented melanin based intrinsic pigmented lesions in all skin types.

As a tattoo removal laser for laser tattoo removal it lacks the power output of some of its competitors such as the Candela Picoway and the Quanta Pico discovery. If DrH ran a tattoo removal service he would potentially choose the Candela Picoway, Quanta Pico Discovery or Fotona Starwalker PQX. These three devices have higher power outputs and smaller pulse widths of 300-450ps that are more suitable for aggressive reduction of tattoos in lighter skin types.

Tattoo removal lasers are essentially a combination of 532nm/1064nm wavelengths. Candela Picoway and Quanta Pico Discovery are excellent mainstay tattoo systems that were mainly designed for tattoo removal but can also be used effectively used in the management of some melanin based pigmented lesions. Candela Picoway is essentially a 532nm / 1064nm dual wavelength picosecond laser that has additional optics that can produce 730nm and 780nm outputs. Although approaching 755nm these optics are potentially more useful from the perspective of treating certain colours of tattoo pigment more safely in darker skin types rather than being focussed at treatment of melanin.

The Candela Picoway is however in my opinion a powerful and reliable tattoo removal device. The 532nm wavelength on the Candela Picoway permits effective treatment of Café Au Lait Macules or superficial pigmented lesions such as solar lentigines albeit with less finesse than the Cynosure Pico Pro. Also when treating these superficial lesions in darker skin types with Candela Picoway you will essentially be faced with the hypopigmentation followed by hyperpigmentation prior to resolution which can confuse the patient. The 1064nm Candela Picoway wavelength also permits treatments of deeper pigmented lesions such as naevus of Ota. Again, due to the relative lack of absorption of 1064nm versus 755nm the Candela Picoway is a much weaker choice versus Cynosure Picosure Pro. Essentially choose the Candela Picosure Pro for a practice that is highly focussed on Tattoo Removal and dabbles in the occasional simple solar lentigo or benign superficial pigment.

However don’t forget if you are a dermatologist wanting to expand your service to incorporate laser for basic superficial pigmented lesions on lighter skin types, laser melasma reduction and management of simple semipermanent make-up tattoos and or traumatic tattoos then a nanosecond Q switch 532nm /1064nm laser such as Cynosure Revlight Si will be a much more cost effective purchase and offer you 70% of the functionality of a Candela Picoway. Here the Picoway would essentially excel significantly in treatment of melasma and tattoo reduction.

Quanta Pico Discovery is another excellent 532nm / 1064nm Picosecond Laser option comparable to the Candela Picoway. It has an excellent peak power output of 1.8GW and a narrow pulsewidth of 300-450ps. This makes it an excellent device for the treatment of tattoos in lighter skin types. Its overall higher peak power output and ability for the user to vary the pulsewidth make it my preference over the Candela Picoway. It will also excel over the Candela Picoway in the treatment of green inks in lighter skin types as it carries a 694nm wavelength option also. Given that green ink tattoos in lighter skin types are very common it is a significant consideration if your practice is a volume tattoo removal practice.

The Fotona Starwalker PQX is the new contender. Its advantage is that versus the Candela Picoway and the Quanta Pico Discovery it has the highest peak power output. This makes it an excellent Tattoo removal device. It also has the lowest picosecond pulsewidth of 300nm. The key limitation here is the 532nm / 1064nm that makes it a lighter skin type laser. Unlike its two competitors it has no additional wavelengths making it difficult to tread carefully and safely in darker skin types. The increased power does however allow the fractional handpiece that enables light induced optical breakdown (LIOB) to be more effective than that of the Candela Picoway Resolve Fractional Handpiece. This will help if you wish to use the laser for skin rejuvenation treatments working on the principle of foci of light induced optical breakdown inducing collagen remodelling within the skin. This additional benefit would be useful in aesthetic practice but certainly not a replacement for ablative CO2/Erbium YAG and non-ablative fractional lasers such as Fraxel or HALO. Obviously, downtime would have to be factored in.

Cutera and Lumenis devices in this arena are unfortunately currently weak contenders. The Lumenis PiQo 4 had significant teething and reliability issues and has since been discontinued, Cutera Enlighten is a picosecond laser system that suffers with reliabiltity issues and also is relatively low powered compared to its competitors.

Non-Ablative Fractional Resurfacing Lasers

These lasers only exist in fractional modes.

These Lasers are used in the treatment of the following:

Main indications

• Skin rejuvenation
• Superficial sun damage and pigmentation
• Improving fine lines, epidermal texture and skin quality
• Mild acne scarring

Specialist dermatological indications

• Melasma reduction
• Reduction of Post Inflammatory Hyperpigmentation
• Treatment of cicatricial/cribiform scarring

The Non-Ablative Fractional Laser is a skin resurfacing laser. It was initially viewed as a tool that would enable effective treatment of atrophic acne scarring with lower downtime, it would also allow for safer treatment of acne scarring in darker skin types. 15 years or so after its development things have moved a long way in the management of acne scarring. It is unfortunately one of the weaker tools for acne scar management. The degree of scar remodelling is mild and will not be greatly enhanced by repeating sessions.

It is however a mainstay device in any dermatology practice equipped with laser, Non-Ablative Fractional Lasers excel in low downtime and low risk skin resurfacing. They also give nice even pigment reduction. Skin texture and fine lines can be reduced in a single treatment that is far more effective than most superficial/medium depth chemical peels.

More advanced uses of this type of laser involve management of Post Inflammatory Hyperpigmentation and Melasma. The ability of the deeper penetrating non ablative wavelengths to coagulate melanin and generate transepidermal extrusion of this melanin via MENDS/necrotic shuttling of pigmentation make it a predictable performer in pigment reduction if used in experienced hands. Prior to Picosecond lasers it was perhaps the mainstay in laser driven melasma and PIH reduction. Advanced uses such as cicatricial scarring management are incredibly niche areas of use for this type of device.

The best device in this category for the last 15 years remains the Fraxel Restore. It is a 1550nm / 1927nm dual wavelength Non-Ablative Fractional Laser that is still the most powerful and effective in its class. It is still manufactured today even though the parent company Solta Medical has been bought and sold many a time. Candela tried to mimic the original with the Frax Pro. Unfortunately, when compared to the Fraxel Restore it is heavily underpowered device and largely targeted for lighter Medi spa use.

The Fraxel Restore remains a dermatology mainstay laser. The 1927nm wavelength carries sufficient power end fractional density to coagulatively remove the whole epidermis if required. This allows it to be an effective laser in removal of sun damage and actinic keratoses. It therefore legitimately carries FDA clearance for this. Much can be done to reduce the risk of skin cancer and improve skin quality over the years and this has been demonstrated recently in a Feb 2023 Dermatalogical Surgery publication by Benson et al. The publication focussed on the risk of non-melanoma skin cancer following Non-Ablative Fractional Laser,

The 1550nm Fraxel Restore wavelength lends to its ability to help with deeper dermal remodelling and pigmentation reduction. This remodelling effect can also be used in the management of textural change and cicatricial scarring from more aggressive procedures such as fully ablative resurfacing.

Sciton has done an excellent job of upgrading the Fraxel to a hybrid fractional non ablative and ablative combined laser. HALO is a hybrid fractional laser that combines the non-ablative 1470nm wavelength along with the ablative 2940nm wavelength, The research behing this was led by Jeffrey Orringer who published work on partial thickness epidermal damage triggering deeper dermal collagen remodelling. It certainly is an excellent laser but technically it is in a slightly different class to the Fraxel Restore being a Hybrid Non-Ablative and Ablative combined fractional laser. From a practical point of view, I use the HALO for many of the indications I would have used my Fraxel Restore. Unfortunately HALO only comes as part of the Sciton Joule X platform. It is a very expensive platform. If one only requires a fractional non ablative laser without the expense and expandability of the Sciton Joule X platform then the Fraxel Restore remains the most powerful and cost effective option vs the Sciton HALO. I have the Joule X platform and thus have HALO as a successor to my old Fraxel Restore. HALO has more advanced energy delivery that adjusts energy delivered and spot size depending on skin surface temperature to ensure safety and consistent depth of penetration. This Realtime monitoring and advanced technology is reflected in the price of Sciton HALO.

Sciton Moxi uses the same 1927nm wavelength and delivery technology as the Fraxel Restore. The Moxi has software limitations that limit its ability to perform more aggressive 1927nm non ablative resurfacing. This is unfortunate. As dermatologists in order to effectively remove actinic keratoses one must use the 1927nm laser in a far more aggressive manner when it comes to depth and density settings. The Sciton Moxi uses software that does not permit an advanced user to override the programmed maximum density settings. This is because of its primary intended use as a Medi spa device. It also has to give way to its big brother HALO in the product line.