Arisa Ortiz, MD, FAAD, is an associate professor of dermatology as well as a director of laser and cosmetic dermatology at University of California in San Diego, CA. She was program chair for the American Society for Laser Medicine and Surgery and a guest editor for the Journal of Lasers in Surgery and Medicine. She is currently a journal reviewer for Dermatologic Surgery Journal, British Journal of Dermatology, and Dermatologic Surgery Journal. Dr Ortiz is renowned as a professional in Mohs micrographic surgery in addition to laser and cosmetic dermatology. She met with The Dermatologist to discuss her session at the 2021 AAD Summer Meeting, “Advanced Laser Techniques.”

Could you tell us a little bit about your presentation at the Summer Meeting?
I am so excited about the Advanced Laser Techniques session, which takes place Saturday, August 7, from 9:00 to 11:00 AM EST. We are going to cover body contouring with Dr Mathew Avram, as well as skin tightening and thread lifts with Dr Catherine DiGiorgio. I’m going to be discussing ablative resurfacing. Dr Adam Wulkan will discuss new techniques for treating pigmented lesions and melasma, which is always an interesting topic. Dr Aria Vazirnia is going to discuss assessing appropriate endpoints and avoiding laser complications, which is very important when using lasers, and Dr Avram will be discussing combining injectables with energy-based devices.

You mentioned that your lecture is going to be focused on ablative resurfacing. What are some of the key takeaways that you want to share?
Ablative resurfacing or fully ablative resurfacing is probably one of the most aggressive treatments that I offer. The number one most important thing is choosing the right candidate. I’ll be reviewing how to choose an appropriate candidate for this procedure.

Then, in terms of optimizing your results, I like to take a combination approach. I pretreat with neurotoxin to relax the muscles. While the patient is healing, they can get the most optimal results, because they are not recreating those creases or wrinkles. Studies have shown that combining or pretreatment with neurotoxins augments your results from resurfacing, so I discuss that more in my presentation.

Pain control can be an issue, so I do highlight my approach to pain control with fully ablative resurfacing, which usually includes topical anesthesia, injectable local anesthesia, and nerve blocks. I also offer laughing gas. Most importantly, there is post care. I review my approach to post care and how to look out for and avoid any kind of complication or infection.

Do you have any algorithm or something to help you decide who would be a good candidate for ablative vs nonablative resurfacing?
Yes, and often it comes down to what the patient desires. Let’s say you have a patient who you think would be a perfect candidate for fully ablative resurfacing because they have more sun damage and deeper wrinkles. However, the patient may have a busy work or social schedule, and they may not want that kind of downtime. I really want to get a sense of what kind of downtime a patient is able to give me. If they want something with minimal downtime, then I would probably do something more like a fractional ablative or even a nonablative resurfacing procedure vs something that is fully ablative, which would include 10 days to 2 weeks of being oozy, bloody, and crusty, and then a month of being red, and a few months of being a faint pink. That really is prolonged downtime. It does give you the most dramatic results, but the downtime is prolonged. I need to get a sense of how much downtime they are willing to give me, and I judge based on that. Often, it is patients who are retired or who can hide out and do not have many commitments.

What’s your personal preference: CO₂ vs erbium-YAG?
I like the erbium because there is less risk of permanent, delayed hypopigmentation, which can be seen with the CO₂ laser. You see this sometimes in older patients in which you cannot treat the neck, so it is like they have this pearly white face and the stark line of demarcation along their jawline. You do not really see that with the erbium.

I think in the past, there was this debate whether you could achieve enough tightening with erbium compared to CO₂, and the newer advances in the erbium devices with added coagulation offers that tightening that was seen with CO₂. Those are equivalent these days.

Does that vary depending on the patient’s phototype when they present?
Yes, CO₂ is not as forgiving in darker skin, whereas erbium is quite forgiving. I still would not treat a skin type V or VI with either ablative; that is too aggressive for someone with dark skin. But certainly, with Asian skin types or Mediterranean skin, the erbium is safer.

Are there any other thoughts that you want to share that you think would be helpful for your colleagues in dermatology to know?
Anytime we are talking about laser techniques, especially when you are first starting out, everyone wants to know, “What's the setting? What setting do you use? What numbers?” I think that the main point about lasers, in general, is that it is not about the settings. It is about the endpoints and knowing what to look for in terms of tissue response. A lot of that will be covered in our session.

Reference
Ortiz A, Avram MM, DiGiorgio CM, Wulkan A, Vazirnia A. Advanced laser techniques. Presented at: American Academy of Dermatology Summer Meeting 2021; Tampa, FL; August 5-8, 2021.