Aesthetic Laser Innovators Discuss What Is Next

Dating back to the early lasers of the 1980s, the field of energy-based devices has continued to evolve at a rapid pace over the past 4 decades, showing no signs of slowing. Modern Aesthetics’ Guest Medical Editor Jill S. Waibel, MD, FACS, FAAD, sat down with 3 fellow pioneers in the field to discuss what developments could be upcoming, as well as some of the important lessons they have learned in their careers. (Editor’s note: This transcript has been lightly edited for clarity and conciseness).

Dr. Waibel: How have imaging and objective measurements helped us? Where are we going with imaging? Will the next innovations make us better?

Dr. Ross: We really need more navigational aids. I always talk about the backup camera on your car as an analogy—that type of imaging, where you measure melanin density, individual typology angle (ITA), and whatever kind of pigment measurement you make as far as visible light technologies is helpful, particularly for pigmented lesions and vascular lesions with long pulse technologies, but not so much for picosecond and nanosecond. They are extremely helpful because you will not get many opportunities to treat people who are untanned; even people from colder regions often get tan on vacations. Having gear that allows you to make more intelligent choices as far as settings and avoiding striping and blistering is very helpful. These tools are very simple. The problem is they need to be easy to use, and the current technology is just a little too cumbersome. Each company is working on better technologies to measure skin pigment. Some will be more visual, where you see the skin, and some will just be numbers; that is helpful. The other imaging tool is optimal coherence tomography (OCT) and measuring skin thickness. You can use ultrasound with a bit less resolution, but is that helpful for really guiding us? Maybe it would guide you to different settings if you are treating a vascular lesion and you saw where the vessels were, or if you were using resurfacing and going to a certain depth, or radiofrequency microneedling. These tools could be helpful but only if they are very easy. If you had told me in 1994 that we would not have a bedside diagnostic kit including confocal microscopy in 2026, I would not have believed you. I thought we would be further than that, and we are not. But it needs to be easy. I always tell any manufacturer: dermatologists work in 20-minute or 10-minute increments. If something starts taking too long, we will not use it.

Dr. Geronemus: Imaging has been mostly an investigative tool, and we have learned a lot from studies on skin thickness, from looking at blood vessels with the OCT to doing real-time imaging. My collaborator Dr. Jordan Wang did an in vivo study on his own arm, comparing various fractional lasers and radiofrequency devices to see how long the channels remained open. Even the non-ablative treatments have channels that remain open for hours after the treatment. This has real-time consequences to our daily practice with laser-assisted drug delivery. For example, when we are treating melasma, we use a low-energy, low-density, non-ablative fractional device, and we realize that the channels remain open for hours, so we are applying topical tranexamic acid, and we have the patient apply when they go home. Even with a CO₂ laser, some of those channels are open for more than 12 hours. It provides a therapeutic opportunity. So, we can learn a lot from imaging, but unless it is practical, we will not benefit from it. Now, some devices give real-time feedback. For example, one of the radiofrequency microneedling devices will make real-time adjustments to the penetration of energy if you are not getting the energy that you think you are delivering. Some lasers can make adjustments to your technique. Ideally, some sophisticated artificial intelligence will do all this for us. We are not there yet.

Dr. Waibel: On that note, how do lasers coexist with radiofrequency, ultrasound, and other energy-based devices? How are you using all of these in your clinic?

Dr. Ross: The answer to that is guided by what you are trying to treat and the pathophysiology. When I see a patient, I am thinking about what is causing the wrinkle or what is causing the sagging. You need to address that region of the skin that is causing that problem. If the patient has a lot of superficial wrinkles and you are doing radiofrequency microneedling 2 mm deep, you are bypassing the solar elastosis, so it does not make sense. However, if you have sagging skin and the skin on the surface is relatively free of sun damage, it might make more sense to do deeper heating. Go by what the histology shows. If you want to go very deep, you might use a high-frequency ultrasound; if not, a newer ultrasound device that is fractional may work. The new fiber lasers go under the skin, tangentially. A lot of these new devices are 980 nm and 1470 nm. Treatment needs to be guided by the pathology, and one of the biggest unmet needs we have involves skin tightening. I tell patients who are interested in skin tightening, “I can help you a little bit, but it will be nothing near what a surgeon can do.” We are not there yet. To get there, it might need to be unsafe. Maybe heat is not even the answer. It may not be realistic, but a non-invasive, non-surgical tool to tighten is a major unmet need.

Dr. Geronemus: I am not as skeptical as you are on the body with some of these devices. With focal point laser technology and parallel beam ultrasound, you can get some improvement. That does not replace surgery, but with the right patient, it is worthwhile.

Dr. Waibel: The surgeons have a huge role. I always tell my patients, “My goal is to get you to your surgery—your facelift or your tummy tuck—and then pick up afterward to help maintain surgical results.”

Dr. Geronemus: In terms of other combinations, we published a paper recently about combining radiofrequency with microneedling and non-ablative fractional to treat acne scarring, and we found that doing both treatments on the same day produced better results than doing them independently or sequentially on different days or different weeks.¹ You can address different types of problems from different avenues, and devices such as ultrasound radiofrequency with microneedling provide another tool, but combination therapy is really interesting and needs to be addressed further. We are currently in the middle of a study combining the newer focal point laser technology with the pulsed dye laser for port wine birthmarks, and we are getting rather nice results in resistant port wines that had just hit a plateau. Combination therapy, whether with different types of lasers or different technologies, is something we should all be exploring.

Dr. Ross: I like to utilize what I call brightening-tightening. A lot of patients have diffuse sun damage, and that is where the thulium is the greatest tool. I was so slow to use it; my ratio of 1550 nm to 1927 nm thulium was probably 8:2, and now it is probably 1:9. It is the best diffuse pigment remover, and when you combine that with foundational work, such as poly-L-lactic acid (PLLA) injections, and fractional lasers for acne scars, or radiofrequency microneedling, it is just a beautiful combination. Patients get really nice results with one visit. Combinations just need to be guided by experience and they need to be goal-oriented.

COMPLICATIONS AND LESSONS
Dr. Waibel: What were some complications that taught you something and changed how you practice and how you approach your clinic?

Dr. Ross: My worst complication was with a patient I treated with a Q-switched alexandrite laser when she was on gold therapy for rheumatoid arthritis. It was Christmas Eve of 2007, and I had just given a lecture in Toronto about this phenomenon. I was talking casually to the patient about rheumatoid arthritis, but when we went into the other room, for some reason, I did not ask her about gold. At the very end of the laser treatment, she had about 20 lentigines, and I decided to treat them. I saw this weird light; I thought the light was wrong in the room. I asked the nurse if the light was flickering. I took my goggles off and looked down, and she had these big, Ash Wednesday-type spots all over her face. I knew exactly what had happened. I asked her, “You have been on gold, haven’t you?” It was devastating because I knew it was going to be like having your car stuck in a ditch, trying to get out. I called Rox. I read his article about the long-pulse alexandrite laser. I remember being very depressed. It took me a year and a half, but I cleared that patient with a long-pulse alexandrite laser and a fractional CO₂, and she still sees me 19 years later. I was lucky that my colleagues in town told her to come back to see me, because when you have a complication, you want to keep the patient in your clinic. If the patient goes elsewhere, you really do not know what will happen. I was very afraid in that case, and it still gets me upset. Now, we ask every patient about gold therapy, and if anyone is on it, I turn off all the Q-switched lasers in the room so that I do not grab one for low-contrast lesions out of habit.

Dr. Waibel: That patient stayed with you, but also, you stayed with her. Whether it is a tiny post-inflammatory hyperpigmentation (PIH) or anything else, communication afterward is so important.

Dr. Geronemus: I had a clinical situation that changed my practice and should change everyone’s practice. This was, fortunately or unfortunately, a relative of my wife who had a full-face resurfacing procedure. On day 3 post-operatively, her twin sister came to visit her with an active HSV lesion on her lip. She gave her a kiss. The next thing we know, she had full facial herpes simplex that ended up hospitalizing her and causing some atrophic scarring that I had to fix. Subsequently, anybody going through a non-ablative or ablative resurfacing procedure in my office gets an antiviral treatment prophylactically. Before we began to do this, we had some other cases of minor flares and one case of herpes zoster. The prophylaxis, even just for 2 or 3 days, is enough to prevent this complication from occurring.

Dr. Anderson: I was running the first human study with the light-activated drug verteporfin. We were doing a cancer trial, and I was admitting patients to the hospital, administering the drug intravenously, and then activating it with light. One patient had a history of alcoholism and marginal liver function, and the drug had some liver toxicity at the time. He died a month after we gave him the drug. I never forgot that. I felt horrible. It taught me, at a soulful level: you are working with other people’s lives. I walked away with an absolute obligation to respect that. I cannot test a cancer drug on myself, but for cosmetic work, I have Rox’s golden rule: do unto yourself before you do unto others. If you are not willing to take a risk, do not pass it on. It was an accident and it was unpredictable, but there it was. Another complication occurred when we invented Q-switched lasers for tattoos. We did not know initially that some tattoo inks change color permanently. One patient had a lip-liner tattoo, and when I treated her with a Q-switched ruby laser, it turned black. You cannot see it turning black immediately; the immediate response is whitening, so it looked as if everything was going well. I was appalled. She looked much worse after my treatment that was supposed to make her look better. We tried multiple times to get rid of it; it didn’t work out. She ended up having her lip excised. I published that case—the first description of laser-induced tattoo darkening.² Now it is somewhat routine. What it taught me was the value of paying attention to end points. I became an “endpoint-ologist.” The best way to know what is going on inside the skin is to pay attention to the immediate responses and understand them in detail. So, I could tell tales of woe, but there is virtue in it.

Dr. Waibel: In today’s world, we have succeeded. We made lasers accessible all over the world—that was the goal—but with that came complications. I even had a patient commit suicide after plasma laser treatment by an OBGYN. With great power comes great responsibility.

Dr. Anderson: This is never-ending. As we change and improve the technology—or even without the technology changing—we have made lasers widely available to people who cannot handle the medical complications they create. We need to keep working on that and continue improving. It will never completely go away.

THE NEXT FRONTIERS
Dr. Waibel: What innovations will mark the next true revolution? Will there be another revolution, or just incremental changes?

Dr. Anderson: There will be multiple revolutions. Revolutions happen when things reach a tipping point. Basic science is necessary, but at some point, you understand something well enough to design solutions. That is engineering. We do not usually talk about engineers, but that is what really creates new capability. We have imaging, digital computing, and artificial intelligence at our fingertips. Selective photothermolysis is nice, but it is limited to targets that absorb light selectively. The ability to target with laser microbeams in an intelligent imaging system kicks the door wide open. Anything in tissue that is visible can be treated, in a drug-free fashion. To me, the next big revolution is image-guided microbeam laser treatment. I want to do that for skin cancer. In dermatology, we are the only people who perform microscopically guided tumor surgery, because our patients are awake. We do not need general anesthesia. Operating rooms cost thousands of dollars an hour. If you could do cancer surgery really fast, with microscopic control, you would open huge opportunities in surgical oncology to be faster and more precise. There are other revolutions, as well. We are in an era of molecular and genetic medicine. Ablative fractional laser delivery of topical molecules is impressive. If we combine that with image-guided selective targeting, I can put any drug into the skin at any structure I want to target. That is another huge leap. And it is not all about lasers and light. When we came up with fat removal by cold, it taught me that what we are good at is energy transfer—physics and biology mixed together. We are working now on something we do not completely understand: melanocytes are cold-sensitive cells. Many pigmented lesions, such as giant congenital melanocytic nevi and Becker’s nevus, are difficult to treat with lasers. We are seeing excellent early clinical results and working to understand it. On the laser side, ophthalmology loves femtosecond lasers, and we do not use them at all in dermatology. That is an opportunity. They can accomplish multiphoton photochemistry with extremely precise cuts. 

1. Hashemi DA, Tao J, Wang JV, Geronemus RG. Combination Radiofrequency Microneedling and 1550-nm Nonablative Fractional Resurfacing for Acne Scarring. Dermatol Surg. 2025;51(6):647-648. doi: 10.1097/DSS.0000000000004555.

2. Anderson RR, Geronemus R, Kilmer SL, Farinelli W, Fitzpatrick RE. Cosmetic tattoo ink darkening. A complication of Q-switched and pulsed-laser treatment. Arch Dermatol. 1993;129(8):1010-4. doi: 10.1001/archderm.129.8.1010.