Dr Christopher Zachary presented a new concept Friday 12^th  August at the Controversies and Conversations in Laser and Aesthetic Surgery  meeting, held in Asheville NC at the Grove Park Inn.  Known as a TRASER, this device is neither a  laser nor an IPL. “It’s a new concept, very simple in design, and quite  powerful. A TRASER is truly tunable, and can produce short or long pulse widths, and with high peak power.”

The brainchild of Morgan Gustavsson MBBS, no such device is  currently available for clinical practice, nor cleared by the FDA. “But in the laboratory, we have demonstrated the potential versatility of a TRASER. It is  clear that this device could replace the KTP, the  pulsed dye laser, and the  ruby laser, to mention but a few.”

The  economics of this paradigm shift are simple; why buy 5 lasers when one TRASER might  provide all the parameters necessary for selective photothermolysis, with improvement  in telangiectases, lentigenes, vascular malformations, hair removal, and so  forth.

High peak powers with narrow band output of variable pulse durations are all achieved without a laser cavity, no filters or filter technology, and a simple, low cost assembly.  This non-coherent, non-collimated light will mimic a laser or IPL once delivered to the skin. Unlike a pulsed dye laser, this device uses non-toxic dyes that are extremely durable. “Furthermore, all  dyes are removed within a closed deionization system”, said Dr Zachary. “It’s clean and green”.

After the presentation, Associate Course Director Rox Anderson confirmed that the TRASER was indeed different from a laser and IPL,  and that photons emitted would result from the Stokes shift phenomenon which is  a well recognized feature of fluorescent dyes. He predicted that the dye would have a long life given that the TRASER design would avoid the development of a triplicate state within the dye. The current pulsed dye lasers require the use of the stabilizing and somewhat toxic ‘cot’ to control this phenomenon.

Dr Dieter Manstein questioned whether the TRASER would be able to produce an adequate fluence for therapeutic efficacy. Dr Zachary indicated that the electro-optical efficiency of a TRASER was about 2.5% …  while most lasers have an E/O efficiency of about 1%. The TRASER energy output in  our studies was significantly higher than required for clinical practice.

Dr Zachary has no disclosures. Dr Gustavsson is the inventor
and patent holder.

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Philips forground, Palomar rear

An ASLMS Update

The science behind a new home-use skin rejuvenating device was presented for the first time at the 2011 ASLMS meeting in Grapevine TX this week. This project is the offspring of a collaborative effort between Solta Medical in Hayward, CA, and Philips, the Dutch electronics giant, based in Einthoven, Holland.  Code named ‘Kovar’, this has been in the works for several years, and is the culmination of smart engineering and careful attention to detail with regard to efficacy and safety.  The device is a fractionated 1435 nm laser with an output of 1.2 Watts. This product is not yet FDA cleared and is as yet an investigational device, and therefore is not currently available for use in the USA, or in Europe.

Its major competitor in the US will be the PaloVia, a first generation device manufactured and sold by Palomar.  The PaloVia is retailing at about $499 and has been a popular item on QVC’s shopping network. “The Philips product is a second generation device which has been demonstrated to be safe and effective”, said Dr Christopher Zachary, Professor and Chair of the Department of Dermatology at the University of California, Irvine.  “It has a sophisticated high speed scanner, similar to the Fraxel line of lasers, and was assessed in an 80 patient study to treat the full face, neck, chest and arms. Patients were instructed to use the Philips laser twice a week for 8-12 weeks”. Immediate side effects included some redness and slight swelling which lasted about 1-2 days.  About 50% patients noticed an improvement after one week, and over 90% at week 8.  There was statistically significant improvement in all study categories (including overall appearance, fine lines, pigmentation – age/sun spots, texture, firmness and radiance) at one week and four weeks after completing the course of treatment.  “It is likely that patients might have to undergo a periodic maintenance treatment, as with any skin rejuvenating regime.”

“Sometimes these multinational companies can be tougher than the FDA on their requirements for safety and efficacy”, said Dr Zachary.  Tissue samples form this IRB approved study demonstrated fractionated microscopic injury in the skin of approximately 200 microns in depth.  And special stains indicated the same mechanism of pigment improvement (transepidermal shuttle elimination) and new collagen formation (procollagen I in the superficial dermis) as with their more powerful physician-owned counterparts. “However, there is no way that these low energy, low density home-use devices are going to compete with the high-energy, high-density lasers that doctors use in their laser practices … not unless they use them for a very long time … which, come to think of it, is a possibility”.

“I am totally in favor of the development of home-use devices so that patients might perform facial rejuvenation (or other treatments like hair removal) in the comfort of their own home.  It just makes sense, both economically and for the sake of convenience.  This is not to say that laser surgeons should be worried they are going to lose any business … it’s probably a different and more expanded group of individuals who will buy these devices.”

Last week, Dr Zachary presented a comprehensive review of Palomar’s PaloVia device at the Anti-Aging Worlds Congress in Monte Carlo. “Both these devices work, and both are both safe.  It will be interesting to see what marketing strategies the companies use.  I guess they’ll have to duke it out in public!”

Dr Zachary is on the Scientific Advisory Board for the Solta/Philips project.   He has an active clinical research program at the University of California, Irvine, and works with several laser companies in the development of new technology. As a dermatologic surgeon, his main interests are skin cancer surgery, reconstruction, laser and aesthetic surgery.

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3rd International Conference,   September 15 – 18, 2010

LaserInnsbruck: Europe’s Answer to the Controversies Meeting!

The surreal Austrian location of Innsbruck was home to the third international meeting of the same name (originally LaserBarcelona) founded by Gabriel Buendia MD, Albert Nemeth MD, and Katherina Russe-Wilflingseder MD.  A world class faculty including dermatologists and plastic surgeons presented the very latest in tissue engineering and remodeling technologies. This forum provided an international environment of intellectual sharing, and was very well attended by physicians, researchers, and the laser industry.

Tissue Copying, Remodeling and Regeneration.

The work performed by R. Rox Anderson MD and colleagues at the Wellman Labs relating to tissue copying is nothing short of sensational. The concept is in some way related Anderson and Dieter Manstein’s work relating to fractional ablative laser surgery. “If one can ablate tiny cylinders of tissue from the skin, and have the donor sites heal up quickly and without scarring, then one should be able to harvest similar sized cylinders of tissue surgically, and utilize this tissue for regenerative and other purposes”. Anderson has now demonstrated this hypothesis in vivo, and it would seem that there is no limit to the applications. “Consider this”, he says, “one could remove 50% of the skin of the face, have the treated site heal up in five days without serious sequelae, and then use the micro harvested tissue to reconstitute large areas of entirely normal new skin, perhaps for patients with severe burns or other skin conditions.”

This presentation dovetailed with other novel presentations concerning the treatment of burn scars. These were all very timely, given the number of armed forces personnel who have survived frequently horrific injuries, only to be left with harrowing and limiting contractures. Elizabeth Russe MD discussed some of the new surgical techniques for improving such scarring. Christine Dierickx MD and Gottfried Wechselberger MD described fractionated laser techniques popularized by Jill Waibel MD and others, which appear to generate new collagen and elastin in tissue devoid of these elastic tissues, and which have made significant functional improvements in those treated.  Consider then what benefit Dr Anderson’s tissue regenerative techniques might have when adapted to deliver normal skin elements in a fractionated manner into scarred tissue. Early evidence indicates that structurally relevant components such as follicular and other adnexal tissues regenerate when distributed in this manner. Watch this space carefully, for the developments are likely to be astounding.

“Dora’s Q4 Technique”: Innovative and Newly Described Technique for Removing Tattoos

Just when you thought that tattoo removal was all ‘old news’, the LaserInnsbruck’s attendees were treated to a most intriguing presentation. Like the jam in a cream puff at an English tea house, Dora Kossida MD served up a delicious study, so simple in its design and yet so insightful, pertaining to the laser removal of tattoos. This rising European star of laser surgery, who studied with Rox Anderson for the past two years, has laid ajar a method to remove tattoos more quickly and more effectively than previously possible.

The concept is based on quadruple laser therapy (Q4) wherein the tattoo is treated four times (in this case with the Q-switched Alexandrite laser) with 20 minute intervals to allow the immediate skin frosting to dissipate. It takes at least this time for the in situ water vapor ‘bubbles’ to be reabsorbed, which otherwise would interfere with the transmission of the subsequent laser pulses. Many of us have treated such tattoos with double treatments, but the Q4 protocol is the first reported series first in pigs and then in humans to be described. Patients were noted to have much faster clearing of their tattoos in comparison to standard single Q-switched laser (Q1) pulsing. The Dora Q4 technique is sure to be a mainstay of future laser therapy for tattoo removals.

Further innovative treatments were described including Suzie Kilmer’s technique of combining Q1 laser therapy and fractionated ablative laser treatment. Originally unimpressive when used alone in the treatment of tattoos, fractionated ablative laser immediately following Q1 laser treatment results in considerable leakage of pigment through the epidermis and is said to hasten the disappearance of the tattoos.

Some of the faculty had the opportunity to visit Ötzi (pronounced ‘oetsi’) the Iceman after the confernce.  Ötzi is the well-preserved natural mummy of a man who lived about 5,300 years ago, who was found in September 1991 in the Schnalstal glacia near Hauslabjoch on the border between Austria and Italy, and who since the discovery remains preserved in essentially the same glacial environment as for the last five thousand years.  Plainly visible on his right lateral ankle were the black tattoos which were possibly part of an ancient therapeutic ritual for chronic arthritic problems. Were he alive today, he might be one of many presenting to their local laser specialist for laser tattoo removal. And these would be recognized as amateur tattoos likely to respond well to multiple laser treatments with one of the three available Q-switched lasers. And should he demand scarless removal with fewer treatments (because of a hasty escape across the Ötztal Alps), what might he now be offered?  Maybe Dora’s Q4 technique!

Personal Thoughts About Teaching, Learning, and Discovering

It is imperative that those of us who teach residents and students encourage exploration in every sense of the word.  The excitement of learning is infectious. But the natural curiosity of our students and residents is thwarted by traditional medical school and residency.  We hammer it out of them. The free exchange of ideas, of customs and traditions make for a richer life personally, academically. Those who risk the rigors of travel and exchange of ideas will find discovery. Profound deductions can be made from simple observations, and there is so much yet to be discovered, probably right in front of our eyes.

Innovation is inhibited when the free mind is obstructed by bureaucracy.   In the United States we are often obstructed by a constipated administration with formality and regulations. LaserInnsbruck 2010 allowed us to show up and have an honest, full and invigorating discussion without having to worry about transgressing some bureaucratic organization whose job it was to make our academic and professional lives complicated. The pendulum has swung too far, and it’s time for some common sense.

That so many innovative concepts were delivered at ‘LaserInnsbruck’ is a great compliment to this meeting and to its organizer Katherina Russe MD, the well known Austrian plastic surgeon, who with her family managed and organized all aspects of the meeting. The touchy feely atmosphere of the LaserInnsbruck meeting was unique among academic meetings, and Dr Russe is to be congratulated for bringing together so many from so far.  In some ways, when I think of this meeting, I am reminded of “The Little Engine that Could”,  for so much goodwill and so many novel therapeutic ideas were created in these few days with such little fanfare. And so, we say “bravo Katherina!”

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I estimate that about 70% of my patients have good results, which means that 3 out of 10 patients are unimpressed.  I am surrounded by dermatology residents and fellows who call it as they see it, and they give me that quizzical look when I recount the original study outcomes, wherein every patient could see obvious improvement.  We are careful to take standard digital images and we compare them diligently. True, we don’t employ the three dimensional Vector system, and neither do I perform ultrasound or MRIs on patients, but frankly if they can’t feel or see the difference, what’s the point? It’s not enough for us to be satisfied that 100% of patients have measureable improvement by U/S or MRI.  Innovativel devices can be killed by hype.

So why are some investigators seeing results in all their patients, and others not. This was one of the issues discussed informally by Christine Dierickx, Henry Chan, Rox Anderson, Arielle Kauvar, and Chris Zachary in Paris recently at Les Journées Parisiennes du Laser 2010 conference, a premier meeting of French laser specialists. Henry Chan has also experienced some patients with little improvement in Hong Kong. Arielle Kauvar has noticed improvement in all her patients. We need to determine from Zeltiq users worldwide whether there are outcome differentials, and if so whether these are related to age and gender, or anatomic, geographic, ethnic, technique or other differences between our patient populations.  These might then provide clues as to the cause of this disparity in outcomes.

While musing over lunch, no doubt thinking ‘we are what we eat’, Rox Anderson suggested that the Californian diet was probably lower in saturated and trans fats, and that their fat might ‘freeze’ differently, whereas the East Coasters who enjoy more Philly cheese steak sandwiches might have longer fatty acid chain adipose tissue, with a more responsive outcome.  While humorous, this thought has merit, and would be easy to study, even retrospectively.

Also discussed was the question of painful responses. Two patients with prolonged and severe pain post-Zeltiq were previously reported in this Blog. At the time they seemed to be absolute outliers.  However, it is clear that there have been a very small number of similar but less extreme painful responses, lasting several weeks. The cause of this painful response is not understood, but could be related to the acute panniculitis itself, or possibly a vascular event, an acute neuritis, or some other noxious stimulus to the fat, the underlying fascia, or possibly the underlying muscle.  Rox reminded us that the glomus cell is involved in the control of vascular shunting in a cold environment, and that these shunts can be associated with significant pain. Given that the Zeltiq suction device effectively shuts off the vascular supply to the affected skin and subcutaneous tissue for 60 minutes, one could predict hypoxic tissue responses, despite the protective nature of the cooling.

The normal sequelae of numbness, a modest burning sensation, and other paresthesias are commonplace for several weeks or months.  All patients should be informed about these. Further, these side effects might be used therapeutically in order to control chronic cutaneous pain syndromes, such as post herpetic neuralgia.

And now, with regard to breast reduction by liposuction, check out www.drlanzer.com

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The issues are twofold, and both are pernicious. Device companies are being squeezed by organizers of certain CME meetings in a pay now and pay later ruse. Companies sign up months in advance to exhibit at a cost of $5-10K. Then they receive a call one to two weeks prior to the actual meeting and are invited to pay another $5-10K to have their device discussed at the podium. No pay … no play. I have know speakers disinvited from talking about a certain generic technology ‘because their sponsor refused to pay up’ in this double squeeze play, and ‘thus their talk would no longer be needed’. Further, new talks are susbstituted by inferior product-specific presentations merely because company ‘B’ agreed to pay up.  Clearly this is flouting CME regulations, and more importantly, is an unhealthy manipulation of power and trust.

It might seem very Pollyannaish of me to hold these sentiments, but there you have it.

Conversely, I would hold the somewhat controversial view that product specific presentations are absolutely appropriate, if billed as such. The increasingly popular trend is for meetings to include technology exhibits or forums as side shows that are well funded and are represented as being exactly what they are, namely product specific promotional information sessions. Much akin to separation of church from state, there is clear separation from the main scientific sessions, and this is fine as far as I am concerned.

As a Medical Director of the SDEF meetings, I am aware that we used to do things differently in the old days ….. But now, all the CME scientific sessions need to be free of commercial bias. The meeting attendees are not always well informed enough to know when they are being snowed. Maintaining an even keel can be difficult, but common sense allows an impartial moderator to steer the content in a straightforward and candid manner. The integrity of a meeting is often based on the integrity of the session moderators, and has little to do with a boatload of CME regulations.

No amount of regulation will prevent the type of unethical end-run that some CME conference organizers are using to line their pockets at the expense of truth.  So this is really a call for moderation, and for achieving a balance, for if we do not get it right, then we will reap the consequences.

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The CME staff are so confused about what is acceptable that presentations are often changed by them without permission, often at the last minute and without informing the speakers.

Device (and drug)  names are removed from PowerPoint slides leaving the audience without any basis upon which to understand the difference between one device or another.

Eyes and periorbital regions are covered in photographs, despite signed use agreements, even in cases depicting pre and post eyelid surgery.

Requirement for talks to be submitted weeks or months before the meetings …. (is anyone really that organized?)

“The pendulum has swung too far”, said Dr Zachary. “It’s time for reason to set in”. If doctors can’t tell the difference between science and a sales job, then our medical schools have failed to educate them appropriately”.

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“Low level light (LLL) is going to be used by most of us in ten years when we can work out how best to manipulate it”. It’s all related to mitochondrial absorption of light. The cytochrome (cell color) absorption of specific wavelengths (630, 670, 810, 900 nm) can control oxygenation of tissue by affecting the nitric oxide (NO) switch. Stress caused by surgery or other injury induces copious amounts of NO, which competes with oxygen tissue binding sites. LLL pulls NO off these key binding sites which allows greater tissue oxygenation (read more by Harvey Whelan   and Uri Oron. This is likely to help all ischemic tissue states, and has even been found to have a significant beneficial effect on acute stroke patients. The exception that both Dr Anderson and Dr Matt Avram stated was that they had a hard time believing the claims made by Zerona that inches could be lost with the use of this device.

Fractionation of Laser Energy

Rox Anderson MD discussed the microscopic effects of fractionated laser surgery at the FSDDS meeting in Naples, FL, Sunday 31^st May. Each area of injury is like a tiny murder, which is pretty innocuous on the grand scale of things, and induces new healing, new collagen. The maximum depth for the non ablative devices is about 1.2 mm “we’re not going to get much deeper than that’, said Anderson.   They also do a pretty good job with fine superficial telangiectases and for atrophic skin conditions. ‘Don’t be in a hurry, because some of these great results take 5 or 6 treatments’.

He reminded us of Dr Jil Waibel’s work who has induced remodeling of scars on a microscopic scale, which has made very significant changes to hypertrophic scars after burns and surgery.  Also, Chad Hivnor MD USAF, who has been treating shrapnel scars on the men and women coming back from the Afghan and Iraq wars. Fractionated ablative surgery has been found to be very useful in reducing both hypertrophic and atrophic scars.

Combination use of fractionated ablative lasers with Methyl-ALA (porphyrin precursor) indicates 10-100 times more agent gets into the deeper skin than would otherwise. There is a very fast uptake of any molecule, which will also include bugs ….. “there’s a ying and yang for everything”. Massaging the topical agent makes no difference in its uptake.

Scarring can occur if the technique and parameters are incorrect, as evidenced by the work by Matt Avram and Christopher Zachary published in separate articles last year.

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It’s impossible for a potential client, be they a prospective patient or purchaser of these devices, to make a serious and clear decision about the ‘right’ device, when these studies, vetted and stamped with the approval of the Journal editors and reviewers, are so clearly full of nonsense. Dr Christopher Zachary, Professor and Chair of UC Irvine’s department of dermatology, together with John Allison PhD and Nazanin Saedi MD, made this presentation to the Dermatology/Plastic section of the American Society for Laser Medicine and Surgery’s annual meeting in Phoenix.

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Comments from our colleagues ran the gamut from brilliant to entertaining to empowering.  Great social events, phenomenal breakfasts and full dinner buffets. Despite the great weather, the auditorium was at near capacity with the attendees being interactive, enthusiastic, and involved. Piece de la resistance was the trademark high definition live video demonstration of fillers and neurotoxins.

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