This is Tony Edwards for Scars1 and I have the pleasure of speaking with Dr. E. Victor Ross. Dr. Ross is Director of the Laser and Cosmetic Dermatology Unit at Scripps Clinic in San Diego. He is also the 2007-2008 President of ASLMS, the American Society for Laser Medicine and Surgery, and is a board member of the American Society of Dermatologic Surgery. His special interests are laser skin resurfacing, non-ablative skin remodeling, and laser treatment of leg veins and acne. He is the author of more than 50 articles and seven book chapters.
Scars1: Dr. Ross thanks for speaking with us today. What research are you working on right now with this technology?
Dr. Ross: Right now we are trying to finesse the settings to optimize our therapeutic outcomes while minimizing the anesthetic requirements and minimizing the patient’s recovery time. So that is the real goal here and what we are trying to do is find the right mix of the different technologies that Palomar has to offer, particularly for pigment and wrinkles.
Scars1: In your presentation you were talking about ablative and non-ablative laser technologies. Generally if a patient has acne scars, is this kind of technology appropriate to use?
Dr. Ross: As far as scars, we use it for either surgical scars, traumatic scars or acne scars. They are the primary areas we use it for, occasionally we will use it on so-called keloid scars or hypertrophic scars, but I have to confess that typically we use it for non-keloid and non-hypertropic scars
Scars1: Does this laser technology work for patients of all skin types/colors? I know there are presentations about working with Latin skin and other skin types.
Dr. Ross: It will work but the one caveat is that it will work with a greater instance of side effects. That doesn't mean long term side effects, but as my pal Chris Zachary likes to say, when you treat Type 4 and Type 5 skin you don't expect hyperpigmentation, you can guarantee it. And I sort of agree, as you go to higher settings, and it depends on the settings, you go to settings that are sufficient to achieve reasonable outcomes, particularly with acne scars you start to have a higher likelihood of having a temporary increase in color.
Scars1: That makes sense. Speaking generally, in your practice and in your research, do you generally prefer to use the ablative or the non-ablative? Does it depend on the scar?
Dr. Ross: Yes, it depends on the scar. For most patients, we'll start with non-ablative for two reasons. First it is safer overall and second it’s easier to do. I guess the third part is that it’s easier for the patient, as the patient doesn't have to walk out with any type of oozing or weeping, so you can walk out with some mild edema that is preferable to having oozing, weeping or bleeding.
Scars1: One of the things I was most impressed about during your presentation was when using the non-ablative laser that you could press the device on the skin and you would get deeper healing of wounds. Is there an outer limit of wound depth that you would need to use a different technology?
Dr. Ross: Well, traditionally one might argue that the wound depth is the depth that should be that is sufficient to address wherever the pathology is. For example, if you are treating most wrinkles, you would be 400-800 microns beneath the skin, on the other hand, many scars, particularly acne scars, can extend a millimeter or so below the skin or even deeper. So it makes sense with scars in general to have deeper wounds that maybe are narrower or with less density. You have two key features you look at when you do fractional procedures. You have the density of the coverage and then you have the depth of the wounds. So we think with scars, higher depths and lower densities are probably preferable.
Scars1: You addressed this in your presentation, but since the readership doesn't have the chance to see your presentation, does it hurt?
Dr. Ross: It does hurt. The ablative tends to hurt more than the non-ablative, but I have to say that it tends to hurt less, for example, than carbon dioxide does. So it does hurt, but usually topical anesthesia is sufficient to achieve adequate pain control.
Scars1: Are there any treatment risks?
Dr. Ross: If you overdo either the density or the depth there is always a risk of creating more scars. Something, obviously you don't want to do, and the other big risk is this temporary pigmentation. But that typically resolves. Infection risk, either ablative or nonablative, is very minimal. We've not yet seen an infection with fractional technology, but it could certainly happen. With the nonablative laser technology, there is virtually no risk of bacterial infection.
Scars1: My last question and you did address this earlier in your presentation, so forgive me. You said generally, in non-ablative cases, patients can go back to work sometimes even that day and in ablative, they need to recover over the weekend or for three or four days before they go back to work?
Dr. Ross: That is correct.