Definition

Laser surgery is a medical procedure that uses laser light to remove diseased tissues or treat bleeding blood vessels. Laser surgery may also be used for cosmetic purposes, such as removing wrinkles, tattoos, or birthmarks.

Alternative Names

Surgery using a laser

Description

A laser is a light beam that can be precisely focused. It is used to treat tissues by heating the targeted cells until they “burst.”

There are several types of lasers, including the carbon dioxide (CO2) laser, the YAG (yttrium aluminum garnet) laser, and the pulsed dye laser. Each laser has specific uses. The color of the light beam used is directly related to the type of surgery being performed and the color of the tissue being treated.

Risks

Possible risks of laser surgery include:

• Bleeding
• Incomplete treatment of the problem
• Infection
• Pain
• Scarring
• Skin color changes

Some laser surgery is done when you under general anesthesia. Be sure to discuss the risks with your health care provider.

Since ancient times, human beings have attempted to modify their physical appearances to conform to cultural ideals of beauty. Many characteristics of human appearance are also considered to be evolutionary adaptations for survival of the human species. Beauty, size, and muscularity advertise one’s health and fertility. The ancient Greek ideal equated symmetry with beauty,^[1] and more recent scientific studies have shown that symmetry is still valued in both male and female faces. The “ideal woman” is said to have a small chin, delicate jaws, full lips, a small nose, high cheek bones, large and widely spaced eyes, and a waist-to-hip ratio of 0.7. The “ideal man” is taller, with a waist-to-hip ratio of 0.9, and rugged features such as a dominant, rectangular face and chin; deep-set eyes; and a heavy brow, suggesting a strong supply of testosterone.^[2]

As Christine Rosen points out, physical appearance has also been linked to moral worth.^[3] Those considered good-looking are more likely to get married, be hired, get paid more, and be promoted sooner. Height is associated with income and leadership positions. Strangers are more likely to assist good-looking people in distress. The pretty/handsome are less likely to be reported, caught, accused, or punished for minor and major crimes. On the other hand, attractiveness is recognized as a special gift, and its misuse is not easily tolerated.

Today, women and men of many cultures diet, exercise, apply cosmetics, and undergo a bewildering array of surgical procedures to achieve a desired look. Yet, many techniques of body manipulation have had profound health effects on the individuals practicing them. Moreover, some have been cultural practices designed to control the female sex, even when willingly accepted by women. Others, such as female genital mutilation, again often accepted by women, involve the abrogation of women’s right to bodily integrity and sexual fulfillment.^[4]

Most interventions have been practiced by women, rather than men, who, as a result of their more privileged position in society, have been able to rely more upon their intellectual, political, and military feats to achieve respectability and to woo prospective mates. Ageism has also historically disproportionately discriminated against women. Whereas older men have been seen as distinguished and sophisticated, women who have completed their childbearing years are more often considered “past their prime” and older women have been the greatest consumers of cosmetic procedures. However, this is changing in American culture particularly, in which “youthfulness” dominates the popular cultural discourse on beauty, and older men comprise an increasingly larger proportion of the cosmetic surgery market.^[3]

“Youthfulness is a…desirable commodity, as Americans in the corporate world are learning. A February 2004 report in the Wall Street Journal described a recent survey by ExecuNet that asked senior-level corporate executives about attitudes toward aging. The result found that “82 percent consider age bias a ’serious problem,’ up from 78 percent three years ago. And 94 percent of these respondents, who were mostly in their 40s and 50s, said they thought age ‘had cost them a shot at a particular job.’ Many executives — male and female — are turning to cosmetic surgery to help them stay competitive.”^[3]

This article takes a brief historical look at some of the modifications people (mostly women) have undertaken to try to achieve particular ideals of beauty, and then focuses on some currently fashionable modifications — namely cosmetics, tanning, body piercing, and botulinum toxin (BOTOX) and dermal fillers. Future articles will consider cosmetic surgery and female genital mutilation.

Aesthetic patients fall into 3 distinct subtypes: enhancement, rejuvenation, and restoration.

Enhancement patients are typically 18-35 years of age, female, and more risk-taking. They are principally interested in altering their appearance in order to improve on what Mother Nature and genetics gave them. They are often focused on a particular concern, such as breast size, lip shape, or body contour, and typically they do not express much interest in preventive skin care. They are frequent sunbathers and users of tanning beds. Beginning points for a discussion of skin health with these patients are complexion (eg, acne, seborrhea, pigmentation disorders), safe sun habits to prevent accelerated aging changes, and the disproportionate incidence of malignant melanoma in young women.

Rejuvenation patients are typically 35-55 years of age, female, and want to look as young as they feel. These patients are focused on the maintenance of their (fading) youthful appearance. They frequently eat a healthy diet, exercise regularly, maintain a fashionable wardrobe, and pursue good skin care. They often believe that they look older on the outside than they feel on the inside. Rejuvenation patients are focused not on enhancing their appearance but on recapturing their youthful visage. They are frequently the victims of sun damage and are usually receptive to messages about sun protection, regular skin self-examination, and reparative skin care. This group is in part affected by the experiences of their peers with skin cancer, other serious skin diseases, or nondermatologic life-altering health issues. They are often mothers and are used to frequent physician office visits for their children. They are usually quite receptive to the suggestion that they have a complete skin examination to identify unrecognized skin changes that may be cancerous or precancerous, and they are interested in new technologies for skin care, cleansing, protection, and rejuvenation. In summary, these aesthetic patients are also great candidates for therapeutic skin care.

Finally, the group known as restoration candidates are men and women aged 55-plus who are usually equally interested in skin health and restoration. Photodamage is their primary skin concern, and they are at high risk for skin cancer. Their goal is to limit or stop skin- and appearance-related aging changes. They are not typically interested in looking better than they were made genetically or in looking younger than their calendar age. They are most interested in looking good for their age compared with their peers. Being the best-looking person in the golf foursome or at the country club is their goal. We sometimes refer to members of this group as ideal aesthetic patients because they are open to messages about skin health, skin care, and photoprotection as well as aesthetic concerns. A great way to start with these patients is to suggest a complete skin examination, supplemented with regular skin self-exams. Almost always, these patients have undiagnosed skin conditions in addition to their aesthetic concerns.

In summary, not all aesthetic patients are created from the same mold, just as not all therapeutic patients are the same. Understanding the unique needs and concerns of all patients is the key to overall patient satisfaction.

WPW:MedScape Dermatology:11/24/2009

It’s clear that the simple fact of growing older is relentless and unstoppable. But experts studying the science of aging say it’s time for a fresh look at the biological process — one which recognizes it as a condition that can be manipulated, treated and delayed.

Taking this new approach would turn the search for drugs to fight age-related diseases on its head, they say, and could speed the path to market of drugs that treat multiple illnesses like diabetes, heart disease and Alzheimer’s at the same time.

“If aging is seen as a disease, it changes how we respond to it. For example, it becomes the duty of doctors to treat it,” said David Gems, a biogerontologist who spoke at a conference on aging in London last week called “Turning Back the Clock”.

At the moment, drug companies and scientists keen to develop their research on aging into tangible results are hampered by regulators in the United States and Europe who will license medicines only for specific diseases, not for something as general as aging.

“Because aging is not viewed as a disease, the whole process of bringing drugs to market can’t be applied to drugs that treat aging. This creates a disincentive to pharmaceutical companies to develop drugs to treat it,” said Gems.

The ability of humans to live longer and longer lives is being demonstrated in abundance across the world.

Average life expectancies extended by as much as 30 years in developed countries during the 20th century and experts expect the same or more to happen again in this century.

A study published last year by Danish researchers estimated that more than half of all babies born in wealthy nations since the year 2000 will live to see their 100th birthdays.

But with greater age comes a heavier burden of age-related disease.

Cases of dementia and Alzheimer’s disease are expected to almost double every 20 years to around 66 million in 2030 and over 115 million in 2050.

Diabetes, heart disease and cancer, and the cost of coping with them in aging populations, are also set to rise dramatically in coming decades in rich and poor countries alike.

Nir Barzilai of the Albert Einstein College of Medicine at Yeshiva University in New York says one way of trying to face down this enormous burden of disease is to look at the biggest risk factor common to all of them — aging.

“There’s one thing everybody is missing,” he said. “Aging is common for all of these diseases — and yet we’re not investigating the common mechanism for all of them. We are just looking at the specific diseases.”

To try to reverse that, Barzilai and many other scientists around the world are studying the genes of the very old and starting to find the genetic mechanisms that help them beat off the dementias, cancers, heart diseases and other age-related illnesses that bring down others who die younger.

By finding the genes thought to help determine longevity, scientists think they may be able to mimic their action to not only extend life span, but, crucially, extend health span.

“It is … looking increasingly likely that pharmacological manipulation of these … pathways could form the basis of new preventative medicines for diseases (of) aging, and aging itself,” said Andrew Dillin of the Salk Institute in California and the Howard Hughes Medical Institute.

Gems says institutional and ideological barriers are standing in the way — and a major one is the longstanding traditional view that aging is not a disease, but a natural, benign process that should not be interfered with.

All three experts say, however, that the ground is shifting in their direction.

There is now a “groundswell” of specialists in aging, says Dillin, who are lobbying the world’s biggest drug regulator, the U.S. Food and Drug Administration, to consider redefining ageing as a disease in its own right.

Major scientific research bodies like the U.S. National Institutes of Health and the Medical Research Council in Britain are also under pressure to put more emphasis — and funding — into studying how ageing increases disease risk.

For biogerontologists, the struggle is to convince people that their goal in unpicking the science behind ageing is no longer life, but healthier life.

“The whole reason that we study the ageing process is not actually to make people live a lot longer, it’s to get people to have a more healthy lifespan,” said Dillin.

He sees it as a matter of re-educating the public and health authorities to see biological aging in a new light.

“When we are in the public arena we tell people we’re working on the aging process, the first thing they think is that we want to make a 100-year-old person live to be 250 — and that’s actually the furthest from the truth,” he said.

“What I want is for a 60-year-old person who is predisposed to have Alzheimer’s to be able to delay that, live to be 80, and get to know their grandchildren.”

 

DK/MedscapeBlog/04/2010

 

JW/MedscapeBlog/05/17/2009

All tissues, regardless of body site, are subject to intrinsic ageing, the result of the passage of time. Few clinically apparent changes occur in intrinsically aged skin until the individual is over 70 years of age at which point fine wrinkles become apparent.^[1] Skin, more than any other organ, is also subject to environmental influences which can lead to extrinsic ageing. One such environmental factor is chronic exposure to sunlight which results in phenotypic changes termed photoageing—inevitably a combination of intrinsic ageing and photodamage. By comparison with intrinsic ageing, photoaged skin is rough, dyspigmented and exhibits both fine and deep wrinkles.^[2,3] Histological examination of intrinsically aged skin reveals atrophy of the dermal extracellular matrix (ECM), with reduced levels of collagen and elastin.^[4] Photoaged skin has a different ECM morphology with solar elastosis—the deposition of dystrophic elastic fibres in the dermis—being a prominent histological feature.^[5] Photoaged dermis contains significantly reduced levels of collagen types I and III,^[6] fewer anchoring fibrils at the dermal–epidermal junction (DEJ; collagen VII)^[7] and loss of the fibrillin-rich microfibrillar architecture in the papillary dermis.^[8] These remodelled ageing phenotypes are thought in part to be due to increased cutaneous expression of matrix metalloproteinases (MMPs).^{[9–11]}

Topical retinoids are used as the clinical, evidence-based ‘gold standard’ for the treatment of photoaged skin.^[12] Numerous studies have shown the reparative effects of topical application of all-trans retinoic acid (RA), which includes the partial restoration of collagens I, III^[13] and VII^[14] and restoration of the fibrillin-rich microfibrillar network.^[15] These ECM changes, together with reduced MMP expression may in part explain the clinical improvement of photoaged skin produced by topical retinoids.^{[16–18]} We showed previously, in a 12-day occluded patch test assay, that a specific cosmetic ‘anti-ageing’ product also has the ability to stimulate the accumulation of fibrillin-1.^[19]

Although prescription retinoids can affect these significant clinical and histological changes in photoaged skin there is scant evidence that any of the plethora of cosmetic ‘anti-ageing’ products can produce similar effects.

References

1. Lavker RM, Zheng PS, Dong G. Aged skin: a study by light, transmission electron, and scanning electron microscopy. J Invest Dermatol 1987; 88:44s–51s.
2. Smith JG Jr, Davidson EA, Sams WM Jr et al. Alterations in human dermal connective tissue with age and chronic sun damage. J Invest Dermatol 1962; 39:347–50.
3. Warren R, Gartstein V, Kligman AM et al. Age, sunlight, and facial skin: a histologic and quantitative study. J Am Acad Dermatol 1991; 25:751–60.
4. Braverman IM, Fonferko E. Studies in cutaneous aging: I. The elastic fiber network. J Invest Dermatol 1982; 78:434–43.
5. Chen VL, Fleischmajer R, Schwartz E et al. Immunochemistry of elastotic material in sun-damaged skin. J Invest Dermatol 1986; 87:334–7.
6. Talwar HS, Griffiths CEM, Fisher GJ et al. Reduced type I and type III procollagens in photodamaged adult human skin. J Invest Dermatol 1995; 105:285–90.
7. Craven NM, Watson REB, Jones CJ et al. Clinical features of photodamaged human skin are associated with a reduction in collagen VII. Br J Dermatol 1997; 137:344–50.
8. Watson REB, Griffiths CEM, Craven NM et al. Fibrillin-rich microfibrils are reduced in photoaged skin. Distribution at the dermal–epidermal junction. J Invest Dermatol 1999; 112:782–7.
9. Varani J, Warner RL, Gharaee-Kermani M et al. Vitamin A antagonizes decreased cell growth and elevated collagen-degrading matrix metalloproteinases and stimulates collagen accumulation in naturally aged human skin. J Invest Dermatol 2000; 114:480–6.
10. Chung JH, Seo JY, Choi HR et al. Modulation of skin collagen metabolism in aged and photoaged human skin in vivo. J Invest Dermatol 2001; 117:1218–24.
11. Brennan M, Bhatti H, Nerusu KC et al. Matrix metalloproteinase-1 is the major collagenolytic enzyme responsible for collagen damage in UV-irradiated human skin. Photochem Photobiol 2003; 78:43–8.
12. Samuel M, Brooke RCC, Hollis S, Griffiths CEM. Interventions for photoaged skin. Cochrane Database Syst Rev 2005; CD001782.
13. Griffiths CEM, Russman AN, Majmudar G et al. Restoration of collagen formation in photodamaged human skin by tretinoin (retinoic acid). N Engl J Med 1993; 329:530–5.
14. Woodley DT, Zelickson AS, Briggaman RA et al. Treatment of photoaged skin with topical tretinoin increases epidermal–dermal anchoring fibrils. A preliminary report. JAMA 1990; 263:3057–9.
15. Watson REB, Craven NM, Kang S et al. A short-term screening protocol, using fibrillin-1 as a reporter molecule, for photoaging repair agents. J Invest Dermatol 2001; 116:672–8.
16. Fisher GJ, Talwar HS, Lin J et al. Molecular mechanisms of photoaging in human skin in vivo and their prevention by all-trans retinoic acid. Photochem Photobiol 1999; 69:154–7.
17. Watson REB, Ratnayaka AJ, Brooke RCC et al. Retinoic acid receptor alpha expression and cutaneous ageing. Mech Ageing Dev 2004; 125:465–73.
18. Lateef H, Stevens MJ, Varani J. All-trans retinoic acid suppresses matrix metalloproteinase activity and increases collagen synthesis in diabetic human skin in organ culture. Am J Pathol 2004; 165:167–74.
19. Watson REB, Long SP, Bowden JJ et al. Repair of photoaged dermal matrix by topical application of a cosmetic ‘antiageing’ product. Br J Dermatol 2008; 158:472–7.

BJD 2009;161(2):419-426. © 2009 Blackwell Publishing

Background: Very few over-the-counter cosmetic ‘anti-ageing’ products have been subjected to a rigorous double-blind, vehicle-controlled trial of efficacy. Previously we have shown that application of a cosmetic ‘anti-ageing’ product to photoaged skin under occlusion for 12 days can stimulate the deposition of fibrillin-1. This observation infers potential to repair and perhaps clinically improve photoaged skin.
Objective: We examined another similar over-the-counter cosmetic ‘anti-ageing’ product using both the patch test assay and a 6-month double-blind, randomized controlled trial (RCT), with a further 6-month open phase to assess clinical efficacy in photoaged skin.
Methods: For the patch test, a commercially available test product and its vehicle were applied occluded for 12 days to photoaged forearm skin (n = 10) prior to biopsy and immunohistochemical assessment of fibrillin-1; all-trans retinoic acid (RA) was used as a positive control. Sixty photoaged subjects were recruited to the RCT (test product, n = 30 vs. vehicle, n = 30; once daily for 6 months, face and hands) with clinical assessments performed at recruitment and following 1, 3 and 6 months of use. Twenty-eight volunteers had skin biopsies (dorsal wrist) at baseline and at 6 months treatment for immunohistochemical assessment of fibrillin-1 (test product, n = 15; vehicle, n = 13). All volunteers received the test product for a further 6 months. Final clinical assessments were performed at the end of this open period.
Results: In the 12-day patch test assay, we observed significant immunohistological deposition of fibrillin-1 in skin treated with the test product and RA compared with the untreated baseline (P = 0·005 and 0·015, respectively). In the clinical RCT, at 6 months, the test product produced statistically significant improvement in facial wrinkles as compared to baseline assessment (P = 0·013), whereas vehicle-treated skin was not significantly improved (P = 0·11). After 12 months, there was a significant benefit of the test product over that projected for the vehicle (70% vs. 33% of subjects improving; combined Wilcoxon rank tests, P = 0·026). There was significant deposition of fibrillin-1 in skin treated for 6 months with the test product [(mean ± SE) vehicle 1·84 ± 0·23; test product 2·57 ± 0·19; ANCOVA P = 0·019).
Conclusions: In a double-blind RCT, an over-the-counter cosmetic ‘anti-ageing’ product resulted in significant clinical improvement in facial wrinkles, which was associated with fibrillin-1 deposition in treated skin. This study demonstrates that a cosmetic product can produce significant improvement in the appearance of wrinkles and further supports the use of fibrillin-1 as a robust biomarker for the repair of photoaged dermis.

BACKGROUND: The purpose of this study was to investigate whether plastic surgeons would perform elective cosmetic surgery on spouses or other family members and how many have done so, the type of procedures, the circumstances under which the surgery took place, and the results. METHODS: Participants were 465 members of the American Society for Aesthetic Plastic Surgery, representing 30.7 percent of the overall sample pool of 1513 members recruited through anonymous, voluntary participation in an online survey. Approximately half (51.8 percent) were 51 to 65 years old, most were men (91.2 percent), and most were from large urban areas; respondents had been in practice for 1 to 40 years. RESULTS: The plastic surgeons who returned the survey were comfortable performing elective cosmetic procedures on family members, the majority having already done so. Eighty-eight percent reported they would operate on a spouse or other family member, and 83.9 percent reported they already had. The main motivation (67 percent) was their belief that they were the best surgeon for the procedure. The most commonly listed operations were rhinoplasty, abdominoplasty, eyelidplasty, face lift, breast augmentation, and liposuction. Patients included spouses, children, parents, cousins, and in-laws, ranging from teenaged males to women in their 70s. The overwhelming majority (94.2 percent) reported no complications, and 99.5 percent believed the patients were satisfied with their outcome. CONCLUSIONS: Survey participants are comfortable with the idea of performing elective cosmetic procedures on family members. Regardless of the invasiveness of the procedure or their relationship with the patient, respondents reported no complications and a high level of patient satisfaction anomalous for any patient-surgeon sample, suggesting that surgeons who operate on family members hold confident opinions of their surgical skills and results.

Plast Reconstr Surg. 2010 Mar;125(3):1018-23.