History of Devices w/ Dr. Vic Ross

Doreen Wu (00:00):
Welcome to Park Avenue Plastic Surgery class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host Doreen Wu, and I'm here with Dr. Lawrence Bass Park Avenue, plastic surgeon educator and technology innovator. Today we are talking with Dr. Vic Ross about the history of laser devices and an overview of laser tissue interaction.

Dr. Lawrence Bass (00:23):
Dr. Ross is a board certified dermatologist who works at the Scripps Clinic in San Diego, California. He's really been a leader in the arena of laser and energy based medicine, conducting a lot of research on these technologies. He completed the laser fellowship at the Wellman Labs in Massachusetts General Hospital. He's been a past president of the American Society for Laser Medicine And Surgery and has served on the board of directors of the American Society of Dermatologic Surgery. He has also won two of the most prestigious awards from the American Society for Laser Medicine and Surgery for his career long contributions in this field. So I'm very happy that he's able to join us today to discuss what's happening in laser medicine.

Doreen Wu (01:22):
Awesome. So let's jump right in and start with some history. Dr. Ross, what do you see as the key historical points of laser devices?

Dr. Vic Ross (01:30):
I think the key historical point was Rox Anderson, who's sort of the founder of a lot of what we do today and my personal mentor. His quest to truly try to treat target selectively. So, and that goes back to 1979. So if you look at the mid 1970s and before, lasers were used sort of as a tool, but there was no design of a laser to treat something specifically on the skin. In other words, people took devices that were already made and tried to fit them for an application like taking a shoe that's too big or a shoe that's too small, as you try to put the foot in there. So Rox Anderson came up with the theory that, look, what if we designed a laser to try to target, for example, red birth marks, which is really how all of this started. And so that goes back to 1979. I have a copy of a letter he wrote, and it was returned to him about how we could design, for example, a light source from an engineer's and a physician's perspective to treat red things selectively. And that really goes back again like 43 years.

Doreen Wu (02:40):
And what insights or eureka moments, so to speak, occurred that produced these advances?

Dr. Vic Ross (02:46):
Yeah, I mean, I think that the real eureka moment was, again, going back to Dr. Anderson because he knew that based on physics, you could target say blood vessels or pigmented lesions selectively. And instead of just trying to target everything with a laser and heating it up, which is really what was done in the 1970s, people tried to just heat things up in general, almost like napalm in the forest. They just went in and took out everything. And the only thing that guided you was your hand guiding the laser like a pin to the right target. But what if you could have a laser that was a large spot, like the size of a quarter, which you're only treating something like a hair follicle or a blood vessel or a small pigment lesion within that large spot. That would be something that'd be very novel.

Dr. Vic Ross (03:34):
And he really was the one who came up with that theory that would work. And it was called selective photothermal. In other words, rather than having everything get hot on the skin, it was extreme localized heating. So this way only the bad guy is targeted, which would be whatever that lesion might be on the skin, A broken blood vessel, so like a broken blood vessel on the nose or a port wine stain, which is a red birth mark in kids or say a brown spot on the skin and just had that heated and spare the good guy, which is the background skin. So that was really the eureka moment that Dr. Anderson probably had in the late seventies, and that was transformed into real technology in the early eighties.

Dr. Lawrence Bass (04:20):
And, you know, then from there, there was this increasing investigation, both on a theoretical or mathematical modeling basis and on an empirical or testing basis, but experimental testing at the university, looking at a very broad range of laser parameters to try to decide what devices we might want to try to build. And this was done with free electron lasers. So these are huge research devices, again, at a university that are made to a linear accelerator, but they allow a wide range of laser parameters so you can test what you're theoretically projecting might work, and then you have to translate that into a clinical laser that can sit in a doctor's office and treat real live patients. So that was kind of a decade of investigation that followed some of the early introduction of these devices. But, you know, these are all short pulsed treatments. So this transition in the eighties and early nineties was to doing short pulse treatments with lasers and things have evolved from there, which will get into in a bit

Dr. Vic Ross (05:40):
Yeah, that's exactly right. And Rox Anderson and Fernanda Sakamoto used a free electron laser roughly about 10 to 12 years ago, and we were able to determine certain wavelengths that were otherwise would be unavailable. And that was very helpful to try to find new targets, for example, like fat or sebum, which has allowed us to start to look at acne, for example, as another application for lasers.

Doreen Wu (06:05):
Now shifting the focus to what these devices can do, you mentioned the sebum and the acne. What are the main aesthetic applications where devices are the primary modality?

Dr. Vic Ross (06:16):
Yeah, I think that the number one application, and it's something I would tell people all the time, is if I look at my 32 patients, I'm gonna see today probably 15 of those patients, we're gonna target red and brown spots on the skin. So if you look at just sheer numbers broken blood vessels, redness of the face, and pigment lesions, like the one I have on my cheek here these are the types of things that we see mostly. And those are two applications where devices I think are the primary go to tool. Which wouldn't have been true necessarily 40 or 50 years ago. For example, you might've used a chemical peel over the entire face in the 1970s and for vessels you would've taken electric tool and traced out the vessels. And looking back in time, chemical peels still have a role, but using electric needle to treat blood vessels and particularly diffuse redness, it really would be a little bit kind of flintstone ish Now to do that. You wouldn't think that anybody would try something that that old. So we made great advances and those are actually two applications where I think devices are clearly on a report card, we get an A and other technologies might get a C or less.

Dr. Lawrence Bass (07:25):
And I think there's a huge impact to those kind of visible features in terms of how clear our skin looks, how young we look. People always think about loose skin and wrinkles, but really red and brown pigment has a huge impact on appearance and cleaning that up has a huge improvement to appearance.

Dr. Vic Ross (07:50):
Yeah, that's right. I mean, a lot of people, I had a patient yesterday who says, "I don't want laser. I think I need plastic surgery now." But she had a fundamental misunderstanding of really what the difference was between the things she wanted treated. I think her main problem was she had thought, well, plastic surgery was a permanent solution to facial texture issues. And I said, Well, they're synergistic. They're complimentary, the surgery would do contouring and changing the foundation of the house, so to speak. But for the paint of the house, you need something that's more superficial, whether that's a peeling laser or laser that treats red and brown. So I think a lot of people, there's kind of a misunderstanding that that, that you can use surgery for certain things and, and lasers for certain things, but sometimes they're the same thing, and oftentimes they're not the same thing. And they're indeed complimentary. And I think that's something that people need to understand. So it's not one or the other. Oftentimes it's something like breakfast and lunch and dinner, you want all three and it's not always gonna work out with one tool.

Dr. Lawrence Bass (09:00):
Yeah. And to follow that analogy a little further, you know, when you have dinner, you, you want your protein, your starch and your vegetable and eating, just a lot of one of them doesn't give you a satisfying a meal as if you have a little bit of all three.

Doreen Wu (09:16):
That's a really great comparison. So it sounds like these devices can have a lot of benefits and achieve many different goals. Now, can you break it down for the average layperson, what are the main types of devices for each application?

Dr. Vic Ross (09:30):
Okay, yeah. We'll start with redness. For example, redness, the initial laser, Rox Anderson came up with 40 years ago was called a pulse style laser. And it's still available. You can still buy a pulse style laser. So that's the number one laser for redness, although there are a lot of other competitors. Now. We also have a, a 5 32 nano laser called an LBO laser or KTP laser, which is really a frequency double neodymium-YAG laser that puts out green light. The pulsed laser puts out yellow light, and there's another device called intense pulse light, which a lot of people hear about. It's called IPL. So a lot of people say, "Oh, I want an IPL," or "I have an IPL." And that's the device. Again, it can target red and brown spots. So this is all based really on green and yellow light or combinations thereof treating red and brown spots. But that's just sort of the way those devices work. So that's, that's an idea of three types of devices that are used for redness, and to some degree, brown spots.

Dr. Vic Ross (10:36):
And then there are other devices, for example, hair removal, hair removals, probably the most popular laser procedure that is done in the United States. They probably more laser hair reduction procedures will be done any other single type of procedure. And there are lots of lasers available for that. The first laser really was well the first device was really IPL for hair removal, and then people went into the ruby laser and then Alexandrite lasers, diode lasers and neodymium-YAG lasers. There's a whole host of lasers for laser hair reduction. And they all work pretty well. Different devices work better for darker skin and lighter skin, but overall the concept is the same. You're selectively targeting the hair follicle and sparing the normal skin. And typically these devices all are equipped with a cooling technology that cools the surface. And that's another revolution over the last 20 years. We used to just use ice in the late eighties and mid eighties and ice is okay, but ice is very unpredictable because it depends on how long you put the ice on the skin all sorts of other nuances where these integrated cooling devices very specific and controlled and work better. I think

Doreen Wu (11:46):
Based on our discussion so far, the general sense I'm getting is that some things are lasers and some are other types of devices. Can you talk a little about the significance of laser versus non laser energy based devices?

Dr. Vic Ross (11:58):
Yeah, I mean, there's a lot of devices outside of lasers or light. One of those is ultrasound, for example. There's a device that uses ultrasound, a few devices now that use ultrasound, which penetrates somewhat deeper to tighten the skin. It's more of a skin tightening type of technology. And there are a whole host of non laser devices that use energy such as radio frequency devices. And these devices heat the skin in one way or another, again, achieved some sort of tightening. So there's a whole host of non laser devices, which have really become more popular in the last 10 to 15 years. And they're well equipped to do certain things. They don't do a great job for the most part of treating pigment and red spots on the surface of the skin. These technologies typically go a little bit deeper and the idea is to heat the skin, generally speaking from inside out and they can do reasonably good things for skin tighten. This whole concept of skin tightening came up years ago, but they're not gonna replace surgery in general.

Dr. Lawrence Bass (12:59):
And I think there's a number of devices that try to follow the same strategies. A lot of what we've been talking about are really devices that function in a photothermal fashion by having light or energy introduced into the skin and then being converted to heat. And it's the heat that creates the therapeutic effect that we're trying to achieve. There are other kinds of laser devices that work somewhat differently and, and in some cases non laser devices. But that's the basic focus of how we're accomplishing things with these technologies.

Doreen Wu (13:42):
One of our main goals on this podcast is to empower listeners and provide them with the knowledge and tools as they embark on their beauty journey. We are really just trying to help our listeners think about how to make their own beauty plan. With that being said, can you elaborate on what the role of device treatments is in this beauty plan?

Dr. Lawrence Bass (14:01):
And I'll just jump in here because in some ways that's not a totally fair question because it's really going to differ to some extent by age or where you are in the aging process. You know, younger folks are maybe trying to perfect their skin, clear up acne, things like that. There are folks that are starting to see aging changes, folks who are well into middle age, and then folks who are really in a postsurgical age group but still want to look their best. And so it might be fruitful. Dr. Ross, if you could to sort of break it down into those groups briefly.

Dr. Vic Ross (14:41):
No, that's great. Yeah. The younger people will come in, if we just start people maybe 25 to 40, the most common thing we see with, with that group of people is pigment problems. The first pigment problems typically melasma, for example, where women get this sort of mask of pregnancy, which certainly you can have without being pregnant. The other thing is acne scarring. So in that group we see a lot of acne scarring. Those are, those are two common applications in that young age group. And generally speaking devices can play a role in those types of concerns. Generally speaking with melasma for example, you're trying to gently peel the skin. Oftentimes we use complementary creams to brighten the skin, acne scarring. We oftentimes use what we call fractional lasers to try to break up the acne scars. These are lasers that create little microscopic dots on the skin, little wounds and that can be popular.

Dr. Vic Ross (15:31):
So those are the two main devices we use for young people. And as we move into the group of 40 to 60 we see a lot more sun damage because there's more time to accumulate sun damage. And then we typically are treating again, still red and brown, dyschromnia. That's probably the most common thing we see here in Southern California. Yesterday I had a beach volleyball player. She's 37 and she's been playing that sport for a long time. And so her body's in great shape, but her skins just had a lot of sun damage even trying to do her best to prevent it. And so that's a patient, you take the red and brown lesions and try to improve that by brighten the skin with different lasers or IPL. And oftentimes those patients may need a little bit of filler and a neuromodulator like Botox to assist. So oftentimes it's a combination of things we do in that group of patients. Those patients do get wrinkles occasionally, especially above the lip. Usually in that group we might do a resurfacing laser to peel some of the skin. So those are the sort of typical devices we use for that day.

Dr. Lawrence Bass (16:39):
And you know, when I think of the older folks, certainly wrinkles and pigment changes and redness are central problems, but skin laxity becomes a big issue. And I often have people in their seventies walk into my office and they might have had a facelift at some time in the past or maybe never had a face or neck lift, but they don't want surgery. They might not be healthy enough for surgery at this point in time, and they'd really like to do something energy based to just take away all the loose skin. And I always have a concern in that group because noninvasive skin smoothing and skin tightening with energy based devices is really pushing the skin and asking the skin to respond in surgery, I go in and I tailor out a couple of inches of skin and I reposition the skin and I know it's going to be sitting in a different position. I know I'm going to get some degree of improvement, but I'm concerned when I see the older patient come in asking for a lot of skin laxity to be tailored out with devices because I feel like their skin may have retired by now and I can push the skin, but it may not respond. What are your thoughts on that?

Dr. Vic Ross (18:07):
Yeah, that's something I see every day. So I see a lot of patients every day who have had a facelift. A lot of these patients are 70 to 75, sometimes younger, but they had a facelift when they were 55 or 65 or sometimes even younger. And they don't want surgery. They have a lot of loose skin on their neck. They have jowling, the lower face is descended a bit and they want to do something nonsurgical. And that's a tough task. I always tell people, again, going back to the report card analogy, when you give out grades for nonsurgical skin tightening, I say the best devices might get a c plus and it's not a failure of the device, to be honest. And there are a whole host of devices, greater than 50 or so, skin tightening devices that use various sources of energy, light ultrasound, radio frequency, electrical energy, and they don't suffer from lack of the design of the engineers.

Dr. Vic Ross (19:01):
It's the skin's response. To ask a device to tighten the skin for somebody who's 75 who has very loose skin it's asking too much. So I tell those patients that if I'd seen you when you were 50, maybe these devices would work reasonably well, but now that you're 75 we might have missed a window, but on the other hand, we'll give it a try if you're willing to accept very modest improvement. So that's the critical, I think, issue is that if somebody's willing to accept modest improvement and the procedure is sort of sold as that, then I think it's reasonable in some cases to provide that sort of service. But to expect somebody to have an energy based intervention to reposition a scan, as Dr. Bass said, is asking too much. It's just, it's like a tablecloth is too big for the table. At a certain point, you have to just kind of lop off the excess tablecloth and these devices can't do that. So if I can take the skin and really take a big swath of it and take it between my thumb and fore finger and you can't ask the device to tighten the skin up that much.

Doreen Wu (20:13):
Most of our discussion up until now has centered around the face. What about the body? Is that still all surgical?

Dr. Vic Ross (20:20):
Yeah, so body contouring and of course a lot of things you can do off the face, right? Red and brown spots. So any application that we use on the face, for example brown spots on the hands, leg veins, all that is fair game for lasers. And just like you would use on the face, you might use various lasers to target specifically red or brown spots. We do a lot of that. We have a lot of people, for example, the whole arm is kind of littered with freckles and lentigines, which are these brown spots. And we'll use something like an intense pulse light device that can cover relatively large areas relatively quickly. Again taking advantage of that selective photothermal to treat only the bad guy and in those brown spots will peel off oftentimes within a month or so.

Dr. Vic Ross (21:06):
So that's helpful. Little angiomas, little cherry spots that people get, we can treat those fairly easily. Body contouring is, is the other kind of part of energy based devices and that's more challenging. So in other words, rather than surgery like a tummy tuck or liposuction do these devices have a role in contouring the body? And they do, but again, the improvement's gonna be more modest than it would be with a more invasive procedure. So for example, cool sculpting where we use cold to try to reshape the abdomen or love handles is not going to be as predictably effective as some sort of liposuction procedure. So, so there are different concessions you make when you move into noninvasive procedures, whether they're on the body or the face. And if you take that into account, you can get some modest skin tightening and some improvement in the contour.

Dr. Vic Ross (22:07):
There's some things we don't do a good job of that are common problems. A lot of women come in and they say their stomach is loose. In other words, it's not that they're overweight, they're working out every day, but they've had children and they have loose skin, men too. The little wrinkles over the knees. A lot of women and men are unhappy with their wrinkles over their knees. They go work out and they see themselves in the mirror and they see these little venetian blind lines running across their knee. And that's another thing I don't think we have a great way to treat. So we can do some very simple procedures off the face. But a lot of them don't work very well. Cellulite, another frontier. People have tried lots of things for cellulite. There's probably 20 or 30 different devices that have been used for cellulite, including a new injectable product. All of which can work okay for selected patients, but we're not really gonna get an A or B on our report card yet for those types of applications.

Dr. Lawrence Bass (23:03):
Yeah, I've actually written about this in a number of book chapters. Body skin smoothing, just to put it in a general category, is an immensely challenging problem because the areas are very large compared to face and neck. There's a lot of weight on those areas, and there are other factors besides what's happening in the skin itself that feed into the appearance deficit, the thing we're trying to fix up. So it's something we can make modest progress with, but it's, it is a frustrating area that in some ways is an unsolved problem in aesthetic medicine.

Dr. Vic Ross (23:44):
Absolutely. Absolutely. It's a common problem and like you said, it's very complex and the areas are large. So if somebody says they want their whole thigh to be tighter or they're behind to be tighter, it's a big task and the areas are large and the procedures would take a long time. And even when you do those procedures, oftentimes they work only a little bit. So we have a long way to go if we're gonna try to do something non-surgical or surgical, I mean, I see people who get thigh lifts and butt lifts and then the scars look bad, and so they, kind of have to wear a lot of clothes to cover the scars, and I don't know if that defeats the purpose to some degree, the procedure. So we just have a lot of opportunities to get better for some of these pretty common presentations.

Doreen Wu (24:31):
We usually focus on beauty and aesthetics, But can you tell us a little about how devices have impacted medical applications for skin in both adults and children?

Dr. Vic Ross (24:40):
Yeah, that's a great question. We do a lot of what I call medical laser dermatology. It's kind of a noble thing, maybe more noble in some ways than some of the more pure cosmetic things. And a lot of that involves pigmented birthmarks and red birthmarks in kids, that can be a port wine stain, that can be what we call nevus of ota, where some patients get this brownish discoloration or gray discoloration of their skin. We have lots of opportunities there. And then that's an area where lasers work quite well and there is no other intervention that's reasonable to use. So that's very helpful. We have lasers that work reasonably well for, like I said, for acne scarring for rosacea, which is a common thing that we use lasers for, where people get sort of redness and acneform like bumps, pustules, pimples, that can be very helpful.

Dr. Vic Ross (25:36):
Poikiloderma, which is this red dyschromia that people get kind of cosmetic, but it's also from the sun and genetics, and that's very, very well treated by laser. So we have a lot of medical things and the list can go on. We treat lupus lesions sometimes with laser, which are sometimes red or brown, there's a host of things. If it's red, we generally have a laser that we use a red laser for, you know, a laser that puts out yellow green light. But it's a laser that's designed, you treat red things, so anything that's red, even psoriasis we can treat with laser. So there are a lot of non purely cosmetic conditions that we can use lasers for.

Doreen Wu (26:16):
Thank you so much Dr. Ross for taking the time to share your insight and expertise with us. And thank you to our listeners for joining us today to hear about the history of high technology devices like lasers in aesthetic medicine.

Dr. Lawrence Bass (26:27):
And I'll add my thank yous, Dr. Ross for joining us this morning. It's tremendous to have your great wealth of expertise and your ability to explain this in such a clear way for people to understand.

Dr. Vic Ross (26:44):
Well, you're welcome. I'm glad to be here. Appreciate the opportunity.

Doreen Wu (26:47):
Thank you for listening to the Park Avenue Plastic Surgery Class podcast. If you enjoyed this episode, be sure to share it with your friends. Follow us on Apple Podcast or Spotify and leave a review. We'll see you next time.

Speaker 4 (26:58):
Thank you for joining us in this episode of the Park Avenue Plastic Surgery Class podcast with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator, and technology innovator. The commentary in this podcast represents opinion. This podcast does not present medical advice, but rather general information about plastic surgery that does not necessarily relate to the specific conditions of any individual patient. No doctor patient relationship is established by listening to or participating in this podcast. Consult your physician to advise you about your individual healthcare. If you enjoyed this episode, please share it with your friends and be sure to subscribe to our podcast on Apple Podcasts, Google, Spotify, Stitcher, or wherever you listen to podcasts.