The Science Behind Laser Treatments Featuring Dr. Daniel Belkin

0:00Hey guys, welcome back to Skin Anarchy. This is Ekta. I'm really, really excited about our guest today because he is truly an expert in this field and I've been really meaning to talk to talk to talk to Dr. Dr. Daniel Balkin, who is a double board certified dermatologist and dermatologic surgeon. And he's also very much an expert in the field of lasers. That's really what I would love to discuss today, Dr. Balkin, is lasers. But welcome to the show. I'm so excited to host you. Thank you so much, Ekta. I'm excited to be here. Thank you for having me. Yeah, it's an honor. I would love to actually kind of get started with learning more about you.

0:33What got you into dermatology? My parents both are doctors, and they always encouraged me to go to medical school. and I kind of resisted for a while and I was really into art actually. So I explored a bunch of things in college and then eventually sort of wasn't sure what to do with myself. I ended up going to medical school and was really drawn to sort of more aesthetic fields because of my interest in art. And I found dermatology and dermatologic surgery, also known as Mohs surgery, which is where we kind of cut out and reconstruct from skin cancers. I found a mentor when I was at Cornell Med School is a well-known Mohs surgeon.

1:14And he and I did some research together. And that's sort of how I got into the field. And then I did residency at USC in Southern California. And then I came back to New York for a fellowship in dermatologic surgery. And usually fellowships in derm surgery include both Mohs surgery and also, depending on the program, some cosmetic and laser. And I did a very laser-heavy fellowship with a man named Roy Geronimus, who was sort of one of the pioneers of laser medicine. I mean, you know, I feel like dermatology, we don't really talk about the field a lot, but it's such a competitive field. And there's so much that is there in terms of specializing that we don't really get to hear about it.

1:58I'm just talking from the medical side. Yeah, it's a very rich field with so many varied places to go. You could focus on allergy or rheumatology, dermatology. And then it goes all the way to sort of lasers, which has a lot of physics to it. A lot of people are drawn to it because it's such a varied field. And sometimes your day can go from sort of a heavy medical case to a procedure to a surgery. You're just a very varied, exciting day. I know lasers is, it's a topic that, you know, we see a lot of it. We see a lot of reference, laser treatments and procedures, but we'd never, as you know, someone on the outside, we never learn anything, I feel like as consumers.

2:40I'd love for you to kind of give us this like laser 101. If you could just kind of tell us about where you first saw lasers come into medicine, especially dermatology, maybe even the first time you use them. When I was in residency, even a lot of our attendings weren't that fluent with lasers. And I think it's just, it's not a very strong component of most residency programs. And I remember that when I was a senior resident, I was tasked with giving a lecture to the younger residents about lasers. And so I really had to learn about the physics behind how these lasers work. and it was really fascinating toward me.

3:25And that's part of why I ended up going into a fellowship that focused on lasers because, and I'll explain now, and I think you'll be fascinated by it too. But basically the field of laser has a lot of different sort of modalities that have different wavelengths and different pulse durations. And all of these things allow the laser to sort of target different molecules in the skin. When in the late press, people will just say, you know, talk about laser as sort of a blanket term, but it really is, of course, very complicated and varied. If a patient comes in and says, oh, my friend came to you for laser, I want laser too.

4:04It's like it can be one of 20 different things that they could be talking about or needing. I think and I think people just know it sort of as laser. But what laser is, is light. So all it is, is light. It can be ultraviolet light, it can be visible light, or it can be infrared light. And all of that exists on a spectrum of wavelengths. And a laser takes a single wavelength of light, and it fires only that wavelength. The way that lasers work is you pick a wavelength that you want to use based on the target that you're trying to get. So different targets in the skin absorb different wavelengths of light in different ways.

4:51And I wish we had some visuals because I could draw you out some curves. But for example, let's talk about melanin. So a lot of people do lasers for hyperpigmentation. A lot of people do lasers for hyperpigmentation. So when you're treating hyperpigmentation, what do you want to target? You want to target melanin because melanin is the pigment in our skin that creates pigmentation. Melanin evolved to protect us from UV light. Melanin at the UV end of the spectrum absorbs a ton of light. And then as you go from UV to infrared light, which is heat, melanin absorbs less and less. rigorously. So if you map that out, you go from UV where it absorbs a lot to blue light where it absorbs a lot, down to green light, down to red light where it absorbs a little bit less, and then infrared light where it absorbs less.

5:50So you want to think about what you're targeting and different wavelengths that target absorbs. So if we want to treat hyperpigmentation, we might choose a light where melanin absorbs a lot of it. So I often use a green light to treat hyperpigmentation. So I would use a green light to treat sunspots because green is very avidly absorbed by melanin because it's closer to blue. You know what I'm saying? Yeah. Yeah. So that's one whole aspect. So you're thinking about the wavelength that you're trying to use because you want to target a certain molecule that absorbs that wavelength. So that's one thing.

6:33And then there's this whole other axis that you're thinking about, which is called pulsation. Pulsation is how quickly the laser fires. And that is proportional to how big the molecule is that you're trying to get. So if you want to get a larger molecule, like a hair follicle, You might use a light that is absorbed by melanin because presumably you're targeting dark hairs, but you want to get a large macro hair follicle. It's not microscopic. You can see it with your eyes. You're going to want to choose something with a longer pulsation. So hair removal lasers will be a light in the visible spectrum, I mean, or near infrared spectrum, but visible or near infrared.

7:24So lasers that are absorbed to some extent by melanin, and they have a millisecond pulse duration. now if we wanted to target a little melanin granule which is totally microscopic and a tiny little thing inside a cell we might choose a wavelength of a similar color it might still be red but it's going to fire much much faster so you're delivering that energy on a smaller pulsation in order to target that tiny molecule and that could be on the order of nanoseconds or picoseconds. So if you've heard of lasers that are like a picosecond laser, like that we use for tattooing, those fire orders of magnitude faster than a hair removal laser.

8:16So if I'm doing, if I'm sort of toning somebody's skin with a picosecond, a red light picosecond laser, and they say, will this get rid of my hair also? I can confidently say no because the pulsation is so fast that it's only going to target the little tiny melanin granules. And in order to get the hair, if they wanted it or if they didn't want it, you know, if it was a man who was worried about his beard, if I wanted to get that, I would have to use a pulsation that was so much slower on the order of milliseconds, which is thousands of times slower. You choose your color and you choose your pulsation.

8:59And that's a really good way to think about when you're learning lasers, how they work. That's so interesting. I did not know that. I'm looking at it like just in layman terms, you know, when you're constantly hitting a ball against a wall or something, you know, like how fast you're hitting it, the force that you're applying overall. So there's a force. And then, you know, so if you think about like, you can apply the same force. I push you with a certain force, but I slowly move you. You're not going to have as much of a reaction. You're just going to slowly move with me. But if I slam you with the same amount of overall force, but over like a split second, then you're going to fly against the wall.

9:44That's how the pulsation sort of relates. It's like to the amount of energy that you're firing. It could be the same amount of energy, but you can fire it quickly or you can fire it slowly. If we fire it slowly, we're heating up sort of a larger area. And if we fire it fast, we're heating up a very small amount of area. I mean, you mentioned hair removal, right? That's where I want to actually ask you about. If you're doing hair removal, does that matter, like the area that the laser is actually treating? Like, does that come into play with things like this? Is it like there are pinpoint instruments versus like larger diameter?

10:20Yes, but a little less important in terms of the physics of it. Okay. It's that's important in terms of the technology you're using. And when lasers get better and better, they often have larger spot sizes. So if you can imagine, if you go get laser hair removal and they have a 10 millimeter or centimeter spot size to do your whole back or your legs, that takes forever because it's a tiny little spot size. That's all of the energy that that machine can muster. As machines get better, you can have larger spot sizes and still deliver the same punch. one day we might have a laser hair removal machine where the spot size is the size of a coke can or you know the you know a larger circle where it would take a minute to do the whole thigh versus a little spot size so that usually that more has to do with how the technology is and how good the devices.

11:27Interesting. That's very interesting. Yeah, because I've heard of that, that it takes forever with hair removal. So that's very fascinating. What are CO2 lasers and what do we really get from them in terms of results? That's a great question. And it's a great segue because we talked about melanin as a target. You can also use blood as a target. So you can use heme, like hemoglobin, the heme molecules. And that has its own curve in terms of what wavelengths of light that absorbs. And so any laser that would be considered a vascular laser or a laser that targets blood vessels would fall somewhere at the peaks of that curve where heme absorbs a lot of that light.

12:12And then you can have lasers that target water. And CO2 is a laser that targets water. And water is usually targeted by lasers in the infrared spectrum. Near infrared is kind of just beyond visible light. So it's just you get red and then the next category would be near infrared. But then you can get into sort of like mid infrared light, where it's an infrared light is basically just heat, but it's still a single wavelength of infrared light. and that targets water in different ways. And you have water at all levels of your skin and body. So if you target water, you can heat up a whole column of skin from the top to the bottom.

13:03And that's what CO2 does. So CO2 targets water and it does so very strongly. And when you look under the microscope at a column that a CO2 laser creates. You see a little column where the skin is gone, so it's totally vaporized. It's burned into nothing. And then you see a layer around that column where the skin is what we call coagulated, where it's damaged and contracted. So when you do a CO2 laser, we consider it an ablative resurfacing laser. We call it ablative because it's vaporizing that little column of skin. When we treat a whole face, for example, you get all of these little columns of vaporization surrounded by coagulation where the skin is sort of contracted and you heal from it.

14:02And you have all of these areas that are not affected so that the healing is relatively quick. And that's what we call fractional. So back in the day, CO2 lasers used to be fully, like full field ablative, where it would just rip off a layer of skin, almost like a really deep chemical peel. And they would be very effective, but they would take a really long time to heal from and they were high risk. Now, lasers are fractional, where it's little columns of injury with normal skin in between that allows your cells to come in and quickly heal up those little columns of injury. So they're much lower risk and much faster healing.

14:47Still, CO2 is a big deal. And healing can take a week of redness and swelling and raw skin because you've created all these little holes in the skin that ooze and have to heal. But it can be a really powerful a laser in terms of tightening and treating wrinkling and sun damage and laxity. So CO2 lasers, then what are some of the most common conditions you use them for? CO2 lasers are great for scars. So, you know, we have CO2 lasers are kind of the gold standard for resurfacing, what we call resurfacing. That means taking old skin, old collagen, and causing enough of an injury where that old damaged collagen is broken down and we get regeneration of sort of new, fresh, firm collagen.

15:42Your collagen is constantly being created and broken down. But as you get older, you're sort of accumulating collagen that's not fully broken down. You're not getting that much new collagen. So you have all this collagen sitting around that sort of frayed and fragile and thin. And when we do the CO2 laser, we cause a lot of destruction and your body comes in and cleans a lot of that up and then replaces it with sort of new, fresh, firm collagen bundles. It's great for scars because scars have abnormal collagen that we want to kind of try to normalize. And it's good for some laxity and wrinkling because wrinkling is from the loss of extracellular matrix molecules like collagen and elastic fibers.

16:32We want to stimulate the fibroblasts to just sort of lay down some new matrix. I really like using CO2. I mean, we can do it for the full face, but it's a big deal in New York. It can be a hard sell in New York. I mean, people are very busy here. It's hard to stay in your apartment all day. You're always seeing people. It's a hard downtime to have a week of swelling and rawness on your face. but certain areas can work really well like around the eye it works beautifully where people start to you know see wrinkling around their eyes and we can see o2 just around the eyes and the eyelids and people can wear sunglasses for a week and it can really firm things up there wow so that's great for men too right because i think men get crow's feet earlier than women yeah i'm trying to find the time for one of my colleagues to do it to me because i'm getting wrinkling around the eyes.

17:26I think it's an area that people really start to see aging first. I think mid-30s and up, you really start to see volume loss and wrinkling around the eyes. I think that's a really common area to start seeing it. Absolutely. Yeah, I've heard that. And also, one thing, I mean, I guess this is a different topic, but I want to tie it into lasers because as you know, you know, acne is at the forefront of conversation, especially for most people that I see, you know, whether it's online or just in conversation, everyone's concerned about acne, whether that's actual active lesions or, you know, post-inflammatory hyperpigmentation or whatever it might be.

18:07That journey is what seems to be talked about the most. What is your take on the treatment of acne and then incorporating laser treatments at some point in for whatever aspect, get an understanding of how it might tie in with acne treatment. Yeah. Yeah. That's a great question too, because there's a group of new lasers out. You know, there's, there's not, it's not often that a completely new type of laser, sort of new modality of new wavelengths comes out. There's always new machines coming out, but they're usually sort of recycling older concepts. So maybe it's a machine with the same wavelength and same pulsation as all the devices before, but it has a larger spot size so you can treat more quickly.

18:51We don't often have kind of totally new technology coming out. There was some new technology in the last couple of years for acne. And it's a wavelength in the near-infrared spectrum that targets sebaceous glands. and acne is a multifactorial process but one of the pathological processes in acne is sort of like overactive sebaceous glands and so if you the thought was if you could target those sebaceous glands and destroy them you could treat acne and you can to some extent I think that they were a little oversold and overhyped because it's only targeting that one factor in the development of acne.

19:45And it just hasn't been quite as good in my experience and what I hear from my colleagues as treating acne medically. You know, and which, of course, we've been doing for decades and decades with the medicine isotretinoin or Accutane, which also shrinks sebaceous glands. but has other effects on the skin that create a more curative effect than the lasers, which only target the sebaceous glands. Usually with acne, I advise my patients to treat it medically, get it sort of under control or cured. And then we use lasers for addressing pigmentation, post-inflammatory redness, scarring, and so on. So any kind of sequelae of acne.

20:33Medical treatment still works better. You can sort of get to the root cause. For example, in women, acne, you know, after your 20s, acne is typically hormonal. And so the first line medicine in women with acne who are in their 20s and above is oral spironolactone, which is blocks the male hormone effects on the follicles. And that's getting to more of the root cause. Somebody who has hormonal acne who ends up doing one of these lasers for acne, it's not quite getting to the right spot. Maybe it sort of puts them into remission for a few months, but you're not really getting to the root cause. I haven't adopted lasers for active inflammatory acne as much yet.

21:22Interesting. Now, you know, Dr. Bogdan, we always hear about this. I mean, I guess more recently I've heard about it is this idea that melanin-rich skin types are, you have to be more careful in terms of what you opt in for when it comes to laser treatments. Can you speak on that a little bit just so we can understand? I mean, is it really a thing where we have to kind of, you know, we can't get certain treatments if you're melanin rich as compared to others? Definitely. You can do laser and melanin rich skin, but you have to have a really good understanding of all of those things that we talked about, like wavelength, pulse duration.

22:03You want to make sure that you're really being precise with what you're targeting. For example, in laser hair removal, what you use for melanin-rich skin is you use a near-infrared laser. Now, as if you remember on the melanin curve, melanin doesn't absorb as much or as avidly in that area of the spectrum. It absorbs really avidly at sort of ultraviolet and blue light and less so at red and near-infrared. But when you're treating melanin-rich skin with a hair removal laser, you don't want to target that you don't want melanin to to be to absorb that light so avidly you want it to absorb it enough to get the follicle if it absorbs it really avidly you're going to create damage and hypopigmentation so you use a near-infrared laser that is gentler on melanin overall and you use a pulse duration that's maybe a little higher than you would normally use.

23:10Because if you remember, polstration determines what sort of target, how big the target is going to be. A larger polstration will target a larger follicle and a small polstration is going to target a melanin granule. So you want to stick to polstrations that are a little higher. If you're treating somebody with very fine vellus hairs in a melanin-rich person, that can be really difficult because you have to turn the pulsation down to get to these smaller hair follicles. And then you start to get into sort of like you're going from milliseconds and you're kind of getting closer to microsecond territory, which can target melanin.

23:47That's why melanin-rich skin is more complicated. There's a lot more target around. If you had, you know, super fair skin and a black hair follicle, you could use, you know, kind of whatever pulsations you want and sort of blast it. and you're not going to be picking up that much laser light around the follicle. But in a melanin-rich person, there's all of this melanin around that's now competing for the laser light. So it is complicated. It can still be done, but you just have to go to somebody who really understands what they're doing. I guess just so people understand, what are some credentials individuals should look for?

24:26If they're going in for a treatment, they are kind of a little scared about this. Like, I want to make sure that I'm not getting anything done that's going to harm me in the long run or, like, take away, you know, pigmentation of my skin. What are some credentials we should look for? That's a great question also because there's a lot of misleading these days. And it's very hard to know sort of what people's training is. Yeah. There's a lot of people who call themselves derms who aren't or call themselves plastic surgeons who aren't. There are people who call themselves doctors who aren't. On the other hand, there are people who may not have traditional training where they did a dermatology residency and a fellowship in lasers, but they've been operating a medispa for 30 years, and they could be really excellent with lasers and dermatologic procedures.

25:24So it can be really hard. I think if you find somebody who's a board certified dermatologist, and you can sort of look up their credentials, board certification means that they did a dermatology residency, and they took the dermatology boards. It doesn't necessarily mean that they're amazing injectors or amazing with lasers, but for the most part, you know they've had a basic level of training. With other practitioners, you don't always know that. It's possible that they are amazing, and maybe through word of mouth you can find somebody who's really good, even if you can't sort of verify what sort of training they've had, but you just don't really know.

26:05I think this is such an important topic. And thank you for for speaking so clearly on this, because I feel very strongly about it as well. I think that the word doctors thrown out around a lot these days, people don't know like anyone with a PhD is called a doctor, you know, and they have absolutely no medical training. I mean, it's it's very difficult, I think, for consumers, because especially with the rise of social media, I'm sure Dr. Buckley, you've seen it everywhere. Everyone's literally doctor so and so and then you dig a little deeper and you figure out you don't even have an MD. right unfortunately i mean it becomes confusing because you have a lot of people speaking about these topics that might be reading from google they're literally you know reading from a resource or like i could open a textbook right now and like read something about lasers that doesn't mean i know what i'm doing the problem is even when you look into it it can be really hard to figure out it they'll say like oh they did a cosmetic um fellowship because they shadowed somebody for a while and they call it on their website, a cosmetic fellowship or kind of more vague terms.

27:06For a consumer, it's really, really hard. And I don't know, you know, I don't think it's going to get easier unless, you know, medical boards or nursing boards or whoever sort of starts to regulate the language a little bit. For me, I can tell because I can read a bio and I can figure out from the bio, like I like, I'm like, that's not a legitimate fellowship. I don't know if anyone else can figure that out no i mean because fellowships are fully funded programs like you yeah like you're competitive you get in and they're funded it's not like that you just determined that you did a fellowship you know a doctor online who like looks at celebrity before and afters analyzes what they do and kind of as a way to promote herself i think and to say like oh they did this wrong and their botox is bad and you know and it's like she is a pathologist which is you know yeah it's like but nobody else would ever know that I looked her up and I could and I figured it out but like that's not how she advertises herself you know so um like if people knew that she like didn't even train in live people you know it's like right they wouldn't necessarily trust it but it's and who knows you know maybe she has a lot of experience doing the aesthetics but still it's just everything is so misleading these days i agree it's a topic that i feel like literally no one's discussing because we do not want to step on people's toes and i'm sorry having gone through medical school and been yelled at by so many doctors in my life in my training you know what i mean and yeah the rigor of it yes you know yes yes yeah it's kind of crazy i mean i i feel like that we need to kind of have that culture though like in today's world for any consumers that are listening in you guys have to question people it's it's okay to ask your doctor what did you train right you know like you're allowed to ask that and they should be happy to tell you they should they if you look on a website and somebody and you cannot figure out what sort of residency they did yeah then you should be skeptical because it should be very you know it should be very clear from someone's bio like what their training was and if you're if you're like having trouble figuring it out, then that's not a great sign.

29:20You know, board certified is a specialty. Like it's recognizing a specialty and no one really talks about that. You said, you know, dermatology or plastic surgery, they're going to have the letters to signify that. Unfortunately, that term has also been co-opted where, you know, sometimes you'll be reading a bio and it'll be a board certified aesthetic PA. Yeah. Like what does that mean? I don't know. So there's some sort of board for when you graduate PA school, I guess. And so you're a board certified PA. And then you've decided that you're aesthetic injector PA. And then so you say you're a board certified.

30:02I don't think you and I are going to solve this today. I mean, it's a hard problem. No, it's a hard problem. But I'm glad that we're talking about it. And I'm glad that we're saying it. Because honest to God, I feel like people are too scared to even say it. But coming back to lasers, I want to ask you about skin tightening. We're seeing skin tightening everywhere. I'm sure you've heard a lot of people talking about like, you know, Ozempic and how it's led to this whole, you know, Ozempic phase. I mean, I'd love for you to speak to us a little bit about some techniques that you utilize or you've seen people really opt in for when it comes to skin tightening.

30:33You know, skin tightening, I consider non-invasive skin tightening the holy grail of cosmetic medicine. There's a few types of technologies that can give you some skin firming, some skin lifting. It's hard to get true skin tightening. With Ozempic and the other GLP-1s, I love those medicines. I actually recommend them to a lot of my patients. I think they're really great medicines and they cause weight loss. And I don't really think that they're doing something specific to facial fat. That's my, I feel some people I think do feel that way, but I think it's just when you lose weight, you lose some facial fat.

31:26And if you lose weight quickly, you can lose facial fat quickly. And then you really see that, you know, you see that laxity much more robustly. So when somebody has ozempic face, you know, where they've lost a lot of weight and they feel very hollow, we talk about ways to re-inflate them with different types of fillers. because in that case, a lot of it is volume loss. We don't want to overuse hyaluronic acid fillers. There's a whole backlash against kind of the overuse of hyaluronic acid fillers. And we can talk about that too. I mean, there's a lot there. You can use them. I think in general, most germs and plastics and well-trained people in this area will use hyaluronic acid fillers very conservatively, little tweaks and things like that.

32:22They won't use sort of 10 syringes at a time. There's a lot of people that will. And I think that there's sort of a totally justified backlash to sort of to that type of way of using them and what that does to your face over time, which is not good. But there are other types of fillers called biostimulatory fillers. And those are non-hyaluronic acid products that stimulate your fibroblasts to make more collagen. And these can be controversial too, because the question becomes sort of what kind of collagen are they making? It turns out that they make both type 1 collagen and type 3 collagen. Type 1 collagen is nice, good, healthy collagen that we want.