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Editor’s Note: Following is Part I in a two-part series on cosmetic dermatology. This month we’re looking at the evolution of rejuvenation therapies and highlighting clinical options on the horizon. Next month we’ll look at the business side of cosmetic dermatology as more nontraditional providers explore adding this service line to their offerings.



Ponce de León’s single-minded search for the Fountain of Youth pales in comparison to the quest of many baby boomers once they’ve taken a hard look at themselves under fluorescent lighting.

Actually, the fight to maintain or regain a certain appearance in today’s youth-obsessed society often starts for women and men as early as the 20s and 30s.

What was once only the purview of the very rich and famous has now been made available to the masses through product lines and therapies ranging from over-the-counter creams and gels to much more expensive technology-based rejuvenation devices.

The good news is that many of these minimally invasive products and procedures are relatively painless, typically have very minor side effects and often achieve desired results. The bad news is each of the previous statements includes a qualifier.

Dr. Michael H. Gold, founder and medical director of Gold Skin Care and the Laser and Rejuvenation Center, and Dr. Brian S. Biesman, FACS, founder of the Nashville Centre for Laser and Facial Surgery, both urge a “buyer beware” mentality when purchasing product lines or selecting a procedure and provider.

Although both physicians said there are some good over-the-counter cosmetic lines now available to assist with facial rejuvenation, it’s difficult for consumers to know what works best in general and specifically works well with their skin type.

“The biggest difference between physician prescription products and those sold over the counter, is the ones sold over the counter don’t have to go through the FDA, so they don’t have to substantiate their claims,” said Biesman.

Gold, who carries several skincare and cosmetic lines including those he has helped formulate, added that sunscreen and skincare products are essential elements to complement other rejuvenation techniques. The issue, he said, is that there are numerous products and indications so it’s important that providers who opt to carry cosmetic lines understand how the products work and for what skin types they are suitable.

Biesman and Gold, who both have clinical appointments at Vanderbilt and train other providers in advanced laser and light techniques, stressed the importance of consumers researching both the procedure under consideration and the provider.

Lasers, light therapy and fillers have come a long way in the past decade, but they aren’t the same as surgery and won’t have the same outcomes.

“There are folks who want to look like they’ve had surgery, and typically technology-based devices don’t do that,” Biesman said, adding that the only slight overlap is in skin tightening technologies. He added, however, that minimally invasive procedures enhance the overall appearance and are appropriate for many conditions on their own or as a complement to surgery.

“A lot of the challenge is really identifying the patient’s condition and then matching a device,” he continued, noting that most devices have a fairly narrow field of scope.

Of equal consideration is choosing a qualified practitioner for the type of procedure. What is safe in skilled hands could have devastating outcomes in the hands of those who aren’t properly trained. Gold pointed to two cases in North Carolina and Arizona that received national attention when young women who were about to undergo laser hair removal in a spa setting slipped into comas and died after what amounted to a transdermal overdose of lidocaine and tetracaine.

However, for those who turn to well-trained physicians with the hopes of tightening, lightening, resurfacing or filling problem areas, there are now many viable options and more on the horizon.

Biesman, who is the president-elect of the American Society for Laser Medicine and Surgery, said the technology explosion utilizing lasers, pulsed light and radiofrequency waves has really occurred since the early 1990s.

“In ’94 we started with devices that were able to produce outstanding results but did so at a high cost of both risk and recovery time,” he said. “The Holy Grail — the end goal — has been to get outstanding results with less risk and recovery time.

“Over the years, we’ve developed a number of different families of devices or categories of devices,” he added of continually improving efficacy and safety.

Gold concurred, noting that devices are much more sophisticated today. He added that while the technology may have changed, the reasons patients seek treatment have remained fairly constant.

“Any way you look at it, acne makes up one-third of all dermatology visits,” Gold said of the treatment of both active acne and acne scars.

Now, he continued, dermatologists have both medical solutions and energy sources in their armamentarium. When aminolevulinic acid (ALA) is combined with the blue light of photodynamic therapy (PDT), it sensitizes skin cells and provides visible improvement for those resistant to first-line therapies. The ALA is absorbed by the sebaceous gland and chemically converts to a light-sensitive agent.

“We can specifically target the bacteria in the acne lesions and leave everything else alone,” Gold explained of the therapy.

In addition to acne, PDT is also often used to treat precancerous growths and severe sun damage.

Intense pulsed light treatment (IPL) is effective at helping to even out skin tones due to sun damage and diminishing the red appearance of rosacea.

“In the United States right now, there are probably 15 different IPLs available. If you go to China, there’s 40,” said Gold. “The difference is cost. Cheap means cheap,” he warned, adding good IPLs are expensive for a reason. “It has to do with the computer systems, the cooling systems and the pulsing of the light.”

While IPLs are great for treating diffuse red discoloration, Biesman noted in his publication, “Face Facts: A Guide to State-of-the-Art Minimally Invasive Facial Rejuvenation,” that lasers are typically required to treat larger vascular lesions such as broken capillaries in the face and legs. Although generally safe, he noted that larger blue vessels carry a somewhat higher risk compared to red-colored vessels due to the extra energy required for treatment.

Facial resurfacing helps answer three common complaints in the battle against aging — the appearance of wrinkles, discoloration of skin and the loss of facial firmness. Ablative resurfacing with carbon dioxide is still considered by many to be the gold standard. The ultimate outcomes are very good; however, patients typically have pinkness of the skin for as long as a month and can count on at least two weeks of “downtime” while they heal.

Gold said that over the last four or five years, fractionated resurfacing has gained in popularity and achieves similar results but with only a couple of days of downtime. However, because only a fraction of the skin is done at one time, it takes multiple appointments, usually four to six visits about a month apart, to complete treatment.

Gold, like Biesman, has been heavily involved in research for many of the newer generations of energy-based devices. Fraxel®, which has been developed over the last five years, is a leader in the fractionated resurfacing technology. The system creates a specific pattern of injury under the skin. Gold described it as creating a tiny hole, followed by a skip area, and then another hole.

“In the space of a pencil tip, I could put a thousand holes,” he explained. “When it heals, it creates new collagen. The results have been remarkable.”

Affirm™, Gold continued, takes the same non-ablative approach as Fraxel® but adds a second laser to give a patient both the rejuvenation effect as well as tightening.

“We now have a whole world of tissue tightening devices that use lasers, light or radiofrequency,” Gold noted. He said that while they are all related to Thermage®, the technology has come such a long way that treatments are now virtually, although not totally, painless.

Of course, that which can’t be tightened or erased can always be filled.

“Botox® (Botulinum Toxin Type A) now is the number-one cosmetic procedure done in the world,” said Gold.

Biesman added that down the road he expects to see both the transdermal delivery of botulinum toxin, as well as “non-Botox modification of facial muscles.”

In addition to toxins, there are a number of other fillers such as collagen and hyaluronic acid (Restylane®) to add volume and create a more youthful appearance. Soon, Gold said, there will be even more competition.

“We have seven filler-type substances right now,” he said. “In the next three years, we’re going to have seven or eight more.”

Changes are happening rapidly throughout the spectrum of cosmetic dermatology as procedures are refined.

“On the immediate horizon, the most interesting series of devices we’re seeing are those that achieve non-invasive body contouring,” said Biesman.

He explained that there are several different approaches being explored, such as focused ultrasound and cooling lasers used to dissolve localized fat deposits.

“The idea is that this would dissolve fat in the body and be excreted naturally,” Biesman explained of the new technology, which probably won’t be available for another 12 to 18 months.

Gold is also very excited about laserlipolysis, which gives patients body-sculpting options in targeted areas. With SmartLipo™, which received FDA approval in October 2006, a physician uses a laser to melt the fat deposits, which are then sucked out of the area.

“Instead of gobs of fat, it’s like taking out melted butter. It’s become almost totally bloodless,” he explained, adding that the risks are lower than traditional liposuction.

In addition to removing the fat deposits, the energy source from the laser tightens the tissue and actually alters the skin above so it adheres faster, giving patients a better look.

However, Gold noted, this is not for full-body liposuction but only for targeted pockets of fat.

Also, he warned, “This procedure is not for every doctor. If you don’t know lasers, you shouldn’t do this procedure; and if you don’t do liposuction, you shouldn’t do this.”

He and plastic surgeon Dr. Joseph B. Delozier III are among the handful of physicians in the state currently performing this technique.

From topical treatments to energy-based technologies, the world of cosmetic dermatology has seen an explosion in devices and treatments. While not the mythical Fountain of Youth, the field certainly offers an effective tool to fight the surface signs of aging.

“We can improve most everyone’s skin now,” concluded Gold.




Dr. Brian S. Biesman, FACS, founder of the Nashville Centre for Laser and Facial Surgery is board certified in ophthalmology and has clinical appointments at Vanderbilt University Medical School in ENT and dermatology, as well as serving as an associate professor for UT Health Science Center. In addition to authoring numerous scientific papers, he has written a textbook on the use of lasers in cosmetic and reconstructive surgery. Biesman engages in clinical research — particularly that directed toward broadening the use of lasers in soft tissue surgery. He is the president-elect of the American Society for Laser Medicine and Surgery.

Dr. Michael H. Gold is the founder and medical director of Gold Skin Care Center, the Laser and Rejuvenation Center, and Advanced Aesthetics Medi Spa. The board-certified dermatologist is an assistant clinical professor of dermatology at Vanderbilt University Medical School and Vanderbilt School of Nursing. Gold is the author of more than 75 published scientific papers and speaks internationally to medical audiences on a broad spectrum of dermatologic topics. He is actively involved in clinical trials and established the Gold Research Group in 1996 and the Tennessee Clinical Research Center in 2002.



February 2008

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