Dr. Lena Fan: Combination lasers for pigmentation – True answer, or a waste of money?
Some lasers we have in our clinic include:Hi, I’m Dr. Lena from Veritas Medical Aesthetics. In Veritas, we have built up a complete arsenal of lasers at our disposal. Patients get curious as to the reason for investing in that many lasers while most other clinics generally limit their use to only a few.
- Fotona Versa 3
- Fotona Verde
- Starwalker Pico NdYAG
- Starwalker Pico KTP
- Starwalker Fractional Pico
- Pro Yellow Laser
- Fraxel Duo
- Fraxel Repair CO2
- Fotona Sup:ER
… And I’ve only named those we use in treating pigmentation!
Why then do we take this approach, when others might find certain lasers more niche and cost-ineffective to purchase and maintain?
This is because we believe that in certain pigmentation conditions, combination treatments go a longer way and are more effective.
Some patients express their concerns when I recommend that their pigmentation is best treated with a combination of lasers.
Questions I have received include:
Are multiple lasers necessary?
Are combination treatments more dangerous than conventional treatments?
Is it money truly well spent?
In my previous article on combination treatments for melasma, I touched on various reasons why combination treatments have largely become the approach to take when treating conditions that affect different components of the skin.
Aesthetic patients, you shouldn’t feel this is a new concept.
Many of my patients are familiar with High Intensity Focused Ultrasound (HIFU)(1) treatments that are used in face and body tightening.
HIFU machines have different transducer handpieces, each of a certain depth, that transfer ultrasound energy into multiple layers of the face to trigger collagen renewal. Our facial anatomy is composed of various structures that complement and should be viewed in conjunction, not in isolation, from one another.
For example, an HIFU Ultraformer 3 procedure that I do for patients who have problems with facial skin laxity would be to use the probes of:
4 MHz, 4.5-mm focal depth targeting SMAS layer
7 MHz, 3-mm focal depth for deep dermis tightening
5.5 MHz, 2-mm focal depth suitable for treatments around the eye
7MHz 1.5mm focal depth for upper dermis rejuvenation
By using multiple handpieces, I am able to deliver focused and precise energy to each layered structure from the upper dermis to the lower dermis and subcutaneous tissue, down to the deeper SMAS layer.
Interestingly, I do not get asked much about the use of multi-depth handpieces for HIFU, but some patients do a double take when combination lasers are recommended to them.
In actuality, the concept is completely identical.
Should only one HIFU handpiece of a fixed depth or energy be used indiscriminately from skin down to the deeper support structures, it may result in diffuse heating throughout the layers, increasing the risk of burns, hyperpigmentation or fat atrophy.
In the same vein, by using multiple lasers to treat a condition, we are able to pick the most suitable instrument to target certain components of disease pathways, while minimising collateral damage to non-related areas.
What benefits do combination laser treatments for pigmentation have over single lasers?
When assessing the effectiveness of combination laser treatments, here are some concerns that patients have:
- How much of my pigmentation can the treatment clear?
- How much of my time will the entire treatment cycle take?
- Am I going to spend weeks or months recovering?
- Will my skin be damaged permanently?
- Will I be left with ugly scarring?
- How much am I going to have to spend in total?
All valid concerns – Let’s go through the benefits and see if we can address these concerns in turn.
Benefit #1: Combination lasers for pigmentation are more efficient (and cheaper!)
“Efficient” is an oft-misused term in aesthetic medicine. When I refer to efficiency in this context, I mean that the total number of treatments needed to achieve similar results is reduced
I am not referring to the idea that a combination laser session is more efficient as it entails a shorter recovery period compared to a single laser session involving a longer recovery period. At the end of the day, the amount of downtime associated with a treatment mostly boils down to the technique being used, and not the laser(3). For instance, the Starwalker Fractional Pico is a laser treatment that can create a spectrum of results from just a mild reddening to a full bloodied face after treatment.
However, with combination treatments, fewer treatments in total are required, and that usually translates to an overall reduction in treatment cycle duration.
While we cannot show after photos due to PHMC regulations, I can show you some photos of how ex-patients with pigmentation looked before treatment, and explain why a combination approach was used to treat them.
This is a photo of one of my patients, a 54 year old Chinese lady with large, patchy melasma on her cheeks. What she has is a “mixed” pattern type of melasma, presenting with both epidermal and dermal components.
In the past, using an older approach, I would have taken 8-10 sessions of Starwalker Pico at $288 per session to see a 45-60% improvement in her condition.
Using a combination approach, I managed to see an almost 70% improvement in her condition, using fewer sessions of combination lasers at a slightly more expensive price of $328 per session.
Benefit #2: Combination lasers for pigmentation do less damage to the skin
Lasers, when used in combination, do not do more damage compared to when they are used individually.
That’s a complete myth.
When combination treatments are tailored for our patients, we select lasers that target certain components involved in pigmentation development at specific layers of the skin (e.g. vessels within the dermal layer).
Each laser in our arsenal has a particular wavelength and pulse duration. A laser used to treat the epidermis (surface layer) of the skin may cause unnecessary surrounding damage if it were to be also used for pigmentation that is situated deeper in the dermis (deeper layers).
By combining a variety of lasers, I am able to customise treatment for different targets and tissue layers, according to the individual needs of a patient’s skin and condition, thus actually reducing unnecessary damage caused(4).
Heart surgeons do not perform a complex heart bypass surgery by simply using one scalpel – an operation cannot proceed without the operating theatre being fully kitted out with surgical instruments. Why should lasers be any different?
Combination laser treatments do not differ too much from what aesthetic patients already are familiar with – individualised tools to treat various aspects of a condition.
At the same time, let us bear in mind that combination lasers are not magic techniques that dramatically reduce downtime or increase healing – it would depend on the type of lasers employed. However, by being more specific and efficient, combination lasers for pigmentation allows for pigmentation to be managed with fewer total treatments needed, and in turn decrease overall spending as well as the time needed for the entire treatment cycle.
That’s the reason why I’ll never use just one laser for pigmentation treatment.
Do you have a question for me?
(1) Hyunchul Park,1 Eunjin Kim, Jeongeun Kim, Youngsuck Ro, and Jooyeon – High-Intensity Focused Ultrasound for the Treatment of Wrinkles and Skin Laxity in Seven Different Facial Areas. Ann Dermatol. 2015 Dec; 27(6): 688–693.
(2) Park YW, Yeo UC. Current and New Strategies for Managing Non-Responders to Laser Toning in the Treatment of Melasma. Medical Lasers 2016;5:7-16
(3) Uddhav A. Patil and Lakshyajit D. Dhami1, Overview of lasers. Indian J Plast Surg. 2008 Oct; 41(Suppl): S101–S113.
(4) M.K. Trivedi, BS, BA,a,b,⁎ F.C. Yang, MD,c and B.K. Cho, MD, PhDd. A review of laser and light therapy in melasma. Int J Womens Dermatol. 2017 Mar; 3(1): 11–20.