Laser skin resurfacing moving into domain of ophthalmologists

Laser skin resurfacing moving into domain of ophthalmologists – laser skin ablation for wrinkle removal

The recent boom in laser skin resurfacing (laser skin ablation for wrinkle removal), usually found in the domain of plastic or cosmetic surgeons and dermatologists, has arrived in ophthalmologists’ office suites. At the centennial meeting of the American Academy of Ophthalmology (AAO; San Francisco, California) last fall in Chicago, Illinois, one of the most actively discussed new revenue sources for ophthalmologists was laser skin resurfacing.

Since 1994, when Coherent (Santa Clara, California) gained approval to market its Ultrapulse C[O.sub.2] aesthetic laser for soft tissue ablation, there has been an explosion of interest in wrinkle removal, fostered primarily by “baby boomers” who are now hitting age 50. It is estimated that about 200,000 laser skin resurfacing procedures a year are being performed in the U.S.

This dynamic growth market has attracted several competitors and new technologies into this $180 million – and rapidly growing – market. Plastic surgeons and dermatologists account for about 90% of the current use of aesthetic lasers, but more recently they have become a multi-specialty product, with sales into the ENT, family practice, gynecology, and ophthalmology medical sectors.

Ophthalmologists are a more likely candidate for performing this procedure than one might initially think. Motivated to fortify their revenues since DRGs (disease-related groups) and managed care have eroded their income, ophthalmologists are a natural to expand into this new frontier for several reasons. Many have already completed basic laser training and have the laser experience required for several ophthalmic procedures (see Table 6 on page 10). This provides them confidence and understanding of basic laser technologies.

In addition, costly advertising for new patients is not absolutely required – as is the case for ophthalmic refractive procedures – because potential skin resurfacing patients (over age 45) present themselves to the ophthalmologist for unrelated vision problems. Most people over age 45 develop presbyopia (near-vision loss) and the majority over age 60 eventually develop cataracts, so the patients most likely to benefit from laser skin resurfacing are already in the ophthalmologist’s office for other reasons.

Lastly, as with many other medical specialties today, ophthalmologists are seeking cash (patient-paid) procedures.

Patient demand for removal of wrinkles is strong and increasing. With the total market for cosmetic procedures increasing due to the growing number of persons hitting age 50, the wrinkle removal segment of the cosmetic market is far outpacing all other aesthetic procedure growth rates.

Table 6

Laser Procedures Commonly Performed by Ophthalmologists

Procedure Laser

Posterior capsulotomy YAG

Pan-retinal photocoagulation Argon (sometimes Krypton)

Retinal reattachment Argon (sometimes Krypton)

Glaucoma procedures Argon/Diode

Refractive procedures Excimer

Source: Biomedical Business International

A survey of top dermatologists, cosmetic, and plastic surgeons across the country showed that 90% of the busiest offices are actively involved in laser skin resurfacing procedures. Ophthalmologists are just entering into this lucrative area, and it is likely that only about 5% of all ophthalmologists in the U.S. are performing laser skin resurfacing procedures. However, judging by the activity at the aesthetic laser booths at AAO, that number should increase rapidly. Laser manufacturers are designing programs specifically targeting ophthalmologists, hoping to persuade about 15% of practicing ophthalmologists to actively perform skin resurfacing procedures.

The cost of an aesthetic C[O.sub.2] laser ranges from $50,000 to $130,000, depending on manufacturer, features, and type. About 60% of those doctors starting a laser skin resurfacing program are opting for the rental approach initially, where a turnkey operation is offered to them for $1,500 per day. A laser is brought to their office or hospital, along with a laser technician who ensures that all safety requirements are met and that there are no delays due to technical problems. The doctor then is assured of not having to cancel any patients scheduled for that day. Other manufacturers offer a demo for a week, at no charge. Doctors are charging anywhere from $2,000 to $6,000 for a full-face resurfacing, depending on region of the country and local competition. Partial procedures such as peri-orbital or peri-oral cost less.

The most limiting factor to this procedure is the amount of downtime – or time it takes for the patient to recuperate – before they can return to work. Extreme redness (erythema), swelling, and a “raw” appearance prevent patients from participating in a normal lifestyle for weeks and sometimes up to months. Even though special make-up can be applied before the healing is complete, this potentially long healing process prevents many patients from going forward with the procedure, especially males who generally refuse to wear make-up. Even so, in patient satisfaction surveys, 85% to 95% of all patients who have had the procedure were satisfied with their results.

The major competitors in the C[O.sub.2] aesthetic laser lucrative market are shown in Table 7.

Results from C[O.sub.2] lasers are produced by ablating the epidermis, some of the dermis, and thermally shrinking the collagen, resulting in a smoother, more firm, youthful look. As mentioned, this produces a raw, red appearance for several weeks or months. Many potential patients need to return to their normal lifestyle in a shorter period of time, and so do not have the procedure performed. It should also be mentioned that patients with darker skin (olive-complected, Asian, Hispanic, etc.) may experience some hyper- or hypo-pigmentation following C[O.sub.2] laser skin resurfacing.

To address those patients who cannot be sequestered for a length of time, along with those with darker complexions, several companies are entering the laser skin resurfacing market with a more gentle erbium laser. Theoretically, the erbium laser works by vaporizing the superficial layers of the epidermis without the thermal effect of a C[O.sub.2] laser, so it does not produce the red, raw appearance like C[O.sub.2] lasers. Patients may have to have sequential treatments, but they can return to work much sooner after each treatment. No long-term data exists yet to verify this theory, but several manufacturers are entering this market in order to expand the patient pool and meet the patient demand for shorter downtime.

In a patient-driven market such as this, it could very well be that the patients – along with their doctors – determine which type of laser treatment they want: C[O.sub.2] with a longer recuperation but with dramatic results, or erbium with shorter downtime but less dramatic results and possibly several treatments.

By the time the American Academy of Dermatology (Schaumburg, Illinois) meets in San Francisco in March, several companies may be marketing an erbium laser for skin resurfacing (Table 8 on page 11).

Another product line entering this market is the scanner, an add-on device that can reshape a 10-watt C[O.sub.2] laser beam into the proper density to achieve the same effect as that produced by a 50- to 100-watt laser. This may be especially important to dermatologists and other multi-specialty groups who used C[O.sub.2] lasers many years ago for removal of standard skin lesions but have since evolved into using specific lasers for specific uses (i.e., a ruby laser for tattoo removal). Many dermatologists and other multi-specialty groups still have an older 10-watt C[O.sub.2] laser around that can now have a scanner added for about $20,000, which effectively converts it to an aesthetic laser for skin resurfacing.

Table 7

Major Competitors in C[O.sub.2] Laser Skin Resurfacing Market

Company Market Share Market Share

in units in $

Coherent 28% 36%

Shaplan 32% 28%

Luxar 10% 14%

Heraeus Lasersonics 18% 14%

Palomar/Tissue Technologies 10% 5%

All others 2% 3%

Note: Coherent and Sharplan have markedly different market shares

when comparing installed units to dollar revenue. That is because

Coherent has fewer units placed, but at a higher price per unit.

Coherent also maintains an active rental program (Sharplan does

not), accounting for fewer installed units.

Source: Biomedical Business International

Although Coherent, Sharplan (Allendale, New Jersey), Heraeus Lasersonics (Milpitas, California), and Luxar (Bothell, Washington) offer scanners that attach to their own systems, three other companies offer scanners that can be added to any manufacturer’s laser. Clinicon (Carlsbad, California), Reliant Technologies (San Francisco, California), and Norcross (the Netherlands) have developed such scanners and have received 510(k) approval for soft tissue ablation. They have targeted those physicians who would otherwise consider purchase of an aesthetic laser cost-prohibitive. Clinicon alone has placed more than 150 units worldwide in recent months.

Laser Aesthetics, a division of New Star Lasers (Auburn, California) and a spin-off of Sunrise Technologies International (Fremont, California), will be introducing a new solid-state laser, purported to be even gentler than the erbium laser. It uses a mid-infrared wavelength that is absorbed deeper in the skin and is coupled with a proprietary cooling technology developed in conjunction with the Beckman Laser Institute at the University of California, Irvine that allows the patient to undergo the procedure without general anesthesia. This laser energy is not absorbed at all by the epidermis, so there is no sloughing of the top layers of the skin causing redness. Instead, it shrinks the collagen below, causing a tightening of the skin. New Star has submitted a 510(k) for general dermatological applications, and is in clinical trials at three U.S. sites for the treatment of rhytides (wrinkles).

Other areas where there is strong patient demand and equal R&D developments are for laser treatment of spider veins, hair removal, and hair restoration. Each of these markets could develop into a potential billion dollar market – but ones that ophthalmologists are considered unlikely to enter.

Table 8

Major Competitors in the Erbium Laser Skin Resurfacing Market

Company Regulatory Status

Aesculap-Meditec 510(k) submitted, response

expected this month

Continuum Biomedical Received 510(k) approval

July 1996

Laserscope 510(k) submitted Dec. 1996

Schwartz Electro-Optical 510(k) submitted

Fotona (Slovenia) 510(k) submitted

Source: Biomedical Business International

COPYRIGHT 1997 A Thomson Healthcare Company

COPYRIGHT 2004 Gale Group