Dr. Fitzpatrick

TRUE GENIUS In the early '80s, when Parrish and Anderson published their theory of selective photothermolysis, the world of medical lasers changed forever. Like all theories that are truly genius, this one was easily understood and appeared obvious after it had been explained. It totally changed the field into one having a specific goal and purpose rather than a random pursuit. The pulsed dye laser based on this theory and made by Candela was the first laser ever made to solve a specific medical problem rather than taking an existing laser and trying to adapt it to a medical use. The magic returned to the world of lasers when we discovered that we could, indeed, target cutaneous capillaries and spare the immediately adjacent tissue. There have been many refinements, variations and adjunctive components added to that initial vascular laser, but it remains the most precise and specific laser in use today.

Of course the whole field has exploded since that time, and many new and innovative cosmetic lasers and laser procedures have been developed over the past 25 years and have become commonplace in the armamentarium of the cosmetic surgeon.

The "fat wars" — non-invasive removal of remodeling of unwanted body fat — have barely begun, but I am sure that five years from now, we will have more than one successful approach to noninvasive body sculpting.

One area in which success has been elusive is nonsurgical skin tightening. Though there have been a number of dramatically successful cases using a variety of devices, no one has been able to develop a device or procedure that has predictability. We have the knowledge and background to make that happen now.

Stem cells seem to be the potential answer to many cosmetic problems. Of course, this may be a field of dreams now, but it will develop further, and I'm confident that laser stimulation will play a role — rejuvenation of photoaged skin, balding scalps, prevention of scars and many other possible applications.

A second truly innovative approach to treatment has been fractional photothermolysis, introduced by Manstein and Anderson in 2003. This fractional treatment protocol has again propelled the whole field ahead just when it appeared we had plateaued. Its use now is primarily for treatment of dyschromia, photodamage and scarring, but I am sure it will also expand into those areas that, as yet, haven't been as successful. The use of energy sources other than lasers has also become commonplace in this arena, and we now see many devices using intense pulsed light, radiofrequency, ultrasound and cryotherapy, as well as combinations. Many of these have also adapted a fractional approach so that higher, more intense energies can be used safely.

DECEPTIVELY SIMPLE As we move ahead in this very exciting area, we can easily see the complexity of this field. One of the dangers faced by physicians entering this arena is the adaptation of this technology without a basic understanding of how the laser is interacting with the tissue being treated. There is often an assumption that all of that has been worked out by others and just "aim and fire." I would urge all physicians involved in the clinical use of lasers to take the time to understand how that laser is working on tissue to produce the desired clinical effects. Once you take that step, you will be a true laser surgeon and ready to contribute to the field and to your patients' well-being.

RICHARD E. FITZPATRICK, M.D., director, dermatology division, La Jolla Cosmetic Surgery Centre, is board certified by the American Board of Dermatology and the American Board of Cosmetic Surgery, a member of the American Society of Dermatologic Surgery, American Academy of Facial Plastic and Reconstructive Surgery and a Fellow of the American Academy of Cosmetic Surgery. He served as President of the American Society for Laser Medicine and Surgery in 2000-2001.