There’s lasers, and there’s lasers – but how do we know what’s good for what, and really is one laser going to solve all your problems? Today we get into the nitty gritty with Sydney Laser Guru, Dr Bruce Williamson from SkinSmart in Balgowlah. In this podcast we find out why Dr Williamson has many laser devices in his clinic and in some cases uses more than one device to treat one problem – such an interesting podcast. Get ready to be enthralled!

Trish: Hey podcasters, I’m here late this afternoon, got something a little bit different to share with you guys today. We’re going to talk to Dr Bruce Williamson. Dr Williamson’s actually a bit of a laser guru and his clinic is actually in Balgowlah near Manly, northern beaches of New South Wales. I met Dr Williamson when I was talking to a device company who knew a lot about lasers and they said to me oh, you’ve got to speak to Dr Williamson. So, after I had a chat with him, I was pretty excited because normally, you find that people have one laser, and this laser’s going to do this, this, this, and this, but Dr Williamson is completely different. He actually has a whole heap of different options for people, because he wants to get the exact right frequency, if that’s the right word, when he’s treating people. So, welcome Dr Williamson.

Dr Bruce Williamson

Dr Bruce W.: Thank you Trish. It’s lovely to be here this afternoon on the podcast.

Trish: Yeah, I’m really excited to have you today. So, what’s the name of your clinic?

Dr Bruce W.: It’s SkinSmart Medical Services, and we’re in Balgowlah, which is in Sydney’s northern beaches, so just across the harbour from the city.

Trish: Awesome. Well, I’m hoping this is going to be one of a few podcasts I have. So today, I thought specifically, if you’re okay with that, I thought we’d talk about Fractionated CO2 resurfacing.

Dr Bruce W.: Yeah, fabulous.

Trish: Yeah. We tend to get a lot of inquiries because no matter what you do to your face, I think the way your skin looks is probably the most important.

Dr Bruce W.: Exactly, the canvas is the most important thing. It’s what we all look at, is the outside of the skin, the epidermis, so it doesn’t matter what you do underneath. If you’re looking at the same old epidermis on the top, you’re really not going to have made as much change in the face as you possibly could. It’s that skin that gives us that glow, that luminescence of health, I think, so it’s a really important thing.

Trish: Totally. So tell us, what actually is fractionated resurfacing? What does it even mean?

Dr Bruce W.: Okay. Well, laser resurfacing has a fairly long history in cosmetic medicine, and it goes back to the 80s. Prior to that, we really had no good skin rejuvenation treatments except chemical peels. Chemical peels actually have quite a long history, but chemical peels, from my point of view, are a little bit less controlled, and because there’s no heat, we don’t get any tightening with those as such. So, when CO2 lasers came out in the 80s, cosmetic doctors were some of the first people to adopt these lasers. Full laser resurfacing is where we use a CO2 laser to take away the whole of the epidermis on the surface of the skin. That, at the time, was a … and still is a fantastic treatment

It was so much better than anything we had prior to that, but the problem is if you take the whole of the surface of the sin off in one go, you have a prolonged downtime and then a prolonged redness afterwards. When I say prolonged, one to two weeks of weeping and scabbing on the skin, and one to two months of redness afterwards, and for a lot of the people, that’s just impossible to do with today’s modern life. So then, about probably 15 years or so ago, someone came up with the idea of producing a fractionated laser. A fractionated laser doesn’t take the whole skin surface off in one go, but takes little portions of it off and leaves little bridges of normal skin in between, so the skin can heal itself from the sides rather than having to heal from below.

What that does, it reduces our downtime to literally a few days, not a few weeks, and our redness to a few weeks, not a few months. So, that’s where fractionated laser resurfacing comes in.

Trish: Okay, so basically, if I need a little bit of a jooj, I don’t want to go down the injectable path, I just need to get my skin looking good, you can just have a one off session?

Dr Bruce W.: Well, no. Fractionated laser is a great treatment. So, one treatment does actually give you a very good result, but to get the optimum result with this type of treatment, you need two to three treatments, because we’re only treating a fraction of the skin with each treatment. Having said that, one treatment will still give you a result, it just won’t give you the same result that a full resurfacing treatment would have in the past. As I said, that’s a huge undertaking, but by being able to fractionate this, or split this treatment up into smaller parts, it means that people can do two or three one-week downtimes rather than one three-week downtime. So it makes it a lot easier for most people to do.

Trish: Okay, so is it something that you should have done regularly?

Dr Bruce W.: Well, it depends on … Where I live in Sydney, it’s a very heavily sun damaged area, and I’m mainly treating people, in the second half of their life, with sun damage. So, certainly that’s what I use the laser for, but it can also be used in younger people to treat acne scarring or for just basic skin rejuvenation. Clear skin is really being able to see the collagen reflectance underneath the skin. When we have dullness from the sun in the form of hyperkeratosis, or redness in the form of capillaries, or pigmentation, that all serves to obscure that collagen reflectance, that luminosity in the skin. By removing that dullness, that redness, that pigment off the surface, it just enables the skin’s normal vitality to shine through. So, that’s what we’re really trying to achieve.

Trish: All right. So, is there any skins that shouldn’t really have it done?

Dr Bruce W.: With any laser that’s generating heat in the skin, the darker the skin, the more we have to work around the pigment, to put it that way. So, the more we have to be careful with your settings and plan around these things. Darker skins or olive skins, both have a problem with hyperpigmentation. If you put too much heat in the skin, you cause what’s called post inflammatory hyperpigmentation, so a transient increase in pigment. That could be quite worrying to someone, and certainly, if you go too hard with any laser and you remove too much pigment, then you can get pale areas which will show up against the darker skin, whereas a fairer skin really doesn’t have those problems.

So, you can treat darker skins. I’ve treated up to Fitzpatrick 5 skins with the CO2 laser, but you have to be aware of the potential limitations and work around those. The laser that I’ve got is a very versatile laser. You can change a lot of parameters on it. So, when we work with darker skins, we can shorten the pulse, reduce that amount of lateral heat that goes into the skin and reduce those type of complications.

Trish: Yeah, because having come into the industry kind of new, and I’m just a consumer, so I don’t really understand the laser terminology [crosstalk 00:06:16], but there’s all these different … there’s some things for some skins, some for others, different frequencies or levels-

Dr Bruce W.: Wavelengths.

Trish: Yeah, wavelengths, that’s it, for different types of treatments. So, as a consumer, you’ve got to really be careful if you’re going to someone, that they know what on earth they’re doing because there’s too many horror stories out there.

Dr Bruce W.: Yeah. It’s certainly not a one size fits all treatment with any of these things. Certainly lasers, when you look at the medical legal side of things, lasers are what put my insurance category up from standard general practise type category to a cosmetic physician. Not using fillers and Anti-wrinkle injections, because the risk with fillers and Anti-wrinkle injections is relatively small, and the regulation is tighter. Whereas with lasers, in New South Wales and in Victoria, there’s no regulation whatsoever. So, from the consumers point of view, you have to be very careful with lasers. As I say, it’s certainly not a one size fits all. I’ve got about six lasers in my practise that I use for pigmentation, or vascular work, or resurfacing, so I’ve got a specific laser for each indication. I think that gives you more versatility with treating different skin types and different conditions.

Trish: So, I remember quite a few years ago where I bumped into this woman. At the time, I think I was in my … I don’t know, I was probably in my 20s, and she was in her 40s. She’d just had laser resurfacing, and her skin looked amazing, but she had it under a general anaesthetic. Is that different to this, or is that same as this but-

Dr Bruce W.: No, full resurfacing … basically, in my practise, I don’t do full resurfacing. I only do fractionated laser resurfacing because I don’t really have facilities for intravenous sedation and for giving people general anaesthetics. As soon as you do that, it changes the level of complexity of your practise substantially because you start to need resuscitation equipment. Certainly with a general anaesthetic, you actually need a second person in the room at all times. You need drugs, and the whole issues with those. With fractionated resurfacing, because we’re only taking off something like 15 to 20% of the skin surface, I use a combination of strong local anaesthetic creams, oral sedation in the form of a benzodiazepine, Xanax, or some Panadeine Forte. I use nitrous oxide. I’ve got a cold air blower, and for the central part of the face, I’ll put in nerve blocks, basically like dental blocks, to numb some of that.

So, I can get relatively heavy resurfacing done in an office without a general anaesthetic, but as soon as you move on to things like full resurfacing, absolutely you need at least intravenous sedation, if not full general anaesthesia. If someone needed that, I would send them off to another facility.

Trish: Yeah, or if someone wanted full resurfacing, you’d get that done as part of a facelift, I guess, or something like that.

Dr Bruce W.: Yeah, usually in combination with something, and usually in a day surgery type environment is where that would be done, yeah.

Trish: All right. That leads me to the next question. So, does it hurt? You obviously use quite a few things-

Dr Bruce W.: Numbing gel?

Trish: Yeah.

Dr Bruce W.: Yeah, I use quite of numbing gel. I like to put that on, at least a couple of coats, and have it on for at least an hour. I think you want a reservoir of local anaesthetic cream on the surface, not just a thin coat, so that’s my first thing. That’s usually sufficient for most resurfacing around the outsides. When we get to the middle of the face, if I want to go harder on the upper lip or the lower eyelid … and they’re two areas where you can get very good results with a laser, and they’re often problem areas for people. So, if I’m just doing general even resurfacing, the person wants to freshen up, I won’t go with the blocker. We can usually just get by with local anaesthetic cream and maybe a little bit of Valium.

If we’re going harder on the lower eyelids or upper lip, then halfway through the treatment when I’ve done the outsides, I’ll stop and I’ll put an infraorbital nerve block in just below the eye. That gives me anaesthesia with the lower eyelid and the upper lip, and then I can go and do those areas quite comfortably. The upper lip is a good area to go hard because you can get rid of the wrinkles there, and you can also evert the lip ever so slightly with the heat, which as people get older, their lips tend to turn in and they have less lip on show. So a little bit of eversion of the lip with the heat is a good thing.

Then on the lower eyelid, it’s good to be able to go within a few millimetres of the lashes, and if someone’s feeling it up there and flinching and moving, it becomes very difficult to do that. Also, you can’t put local anaesthetic cream that close to the eye, because eventually, the tears will leak that into the eye and it starts to sting quite … It’s not something you want to get in the eyes. So, because that’s a limitation with the cream, if I’m going to do the lower eyelid quite hard, quite firmly, I’ll actually put a block in there. Then I can resurface the lower eyelid fairly well.

Trish: Okay. So when you said eversion … Is that right?

Dr Bruce W.: Eversion.

Trish: So what does that actually mean? That’s kind of a-

Dr Bruce W.: Just turning it out, shortening the skin between the red part of the lip … When I’m talking about the lip, I’m not talking about the red part of the lip, I’m talking about the cutaneous lip, the area above the red part of the lip between the nose. So, sometimes when doctors talk about that, they usually mean the whole structure, not just the red part you put lipstick on. So first of all, that’s what I’m talking about. So, if we use the laser and go fairly hard there … and with the CO2 laser, we can put a fair bit of heat into the skin. So, if we put the settings to actually cause a bit of heat, we can get some collagen contraction in the front of the skin there. That will tend to relatively shorten the outside and pull the top part, or turn the top part of the lip out ever so slightly.

It might only be a millimetre, but as people age, women age particularly, because of oestrogen levels dropping, their lips tend to regress and involute a little. That means that the lip will flatten and turn in, and that’s part of the reason that there is less lip on show. Now, some women may not want to have lip fillers put in because they don’t want the plumped, volumized look, but by shortening the skin with the laser, we can evert, or turn the lip out ever so slightly and give them more lip on show without changing the shape of their lip in any way. Of course, you can also do that with filler as well for that matter. It’s not an either or, but you can actually get a little bit of lip eversion, or turning out with the CO2 laser.

Trish: Okay. So basically, if someone comes to me and says, “Oh my god, I’ve been smoking too long. I’ve just quit smoking, and I’ve got these lines on the top of my lip,” is that what it’s going to be perfect for as well?

Dr Bruce W.: Yep, it can certainly help with those. Those kind of lines on the lip mainly occur in women. While they’re called smoker’s lines, and they can occur in smokers, they occur in many people who aren’t smokers. From my point of view, what I think mainly causes them is the hormone reductions that occur in perimenopause and menopause, because the lip in women is a sexual signalling organ, so when you see a young 20 year old with budding pink lips, that’s basically screaming oestrogen. That’s saying, “I’m fertile.” Now, as women come into their 40s and perimenopause, their oestrogen levels relatively drop and they tend to notice these smokers or pursing lines on the top, a loss of colour in the lip, and a relative shrinkage of the lip more than men do.

Men’s lips aren’t a testosterone dependent organ as such, whereas I think women’s lips are. So you often find in women, around their mid to late 40s, around the mouth and perioral area is a problem area for them. So we can do resurfacing on those lines as you say, but I can also put filler individually into the lines on the upper lip, which is quite an effective treatment as well. We can also use the CO2 laser across the red part of the lip as well to rejuvenate the actual mucosal membrane and make it pinker, less dry, less chapped. When I do that, I usually do it in combination with platelet rich plasma. So, I’ll inject some plasma into the lip, and I’ll also put some on the outside of the laser wounds as a wound dressing after I’ve done the CO2 laser in that area. You can get quite substantial lip rejuvenation with that.

Trish: Yeah, right, so basically, it’s not a one fit fits all. If someone come and see you and say, “Okay, this is what I don’t like,” you might do a combination of therapies, might do a bit of CO2 laser, a bit of filler.

Dr Bruce W.: Absolutely. All of this, for me, is combination therapy. It’s the four Rs of rejuvenation, relax the muscles with Anti-wrinkle injections, refill the deficits with fillers, resurface the skin with lasers, and reposition the skin with surgery. So, that’s how it all fits together. It’s not is one better than the other. All these things work in combination.

Trish: Of course. All right, so tell me, with the fractional CO2 resurfacing, are there any risks?

Dr Bruce W.: There are far less risks with fractionated resurfacing than there were with full resurfacing. With full resurfacing, by taking the whole of the surface of the skin off, we’re relying on the skin to regenerate from underneath, from the little islands of cells that are left on the bottom of the hair follicles and bottom of the oil glands. On the face, there are a lot of these little islands of cells, so the face can regenerate from underneath, but with areas like the neck and chest and the hands, they were no go areas for full resurfacing because that skin won’t actually regenerate from below. With fractionated resurfacing because we’re only removing 15, 20% or so of the skin surface and we’re leaving all these little bridges and islands of normal cells which contain the stem cells, the skin rejuvenation cells, the skin can regenerate from the sides, and so it’s much safer.

So, in the past, the main problems with full resurfacing were either prolonged redness, and when I say prolonged redness, I’m talking for months after the treatment. That was because too much heat was just pumped into the surface of the skin, and it didn’t heal properly, or else delayed hyperpigmentation or paleness, which was a problem that came out a few months after laser resurfacing. It was caused by the fact that the excess heat had killed all the pigmentation stem cells, and the person was left with areas of porcelain like whiteness, which look very odd. They look fine covered with makeup, but they look odd without that. So, fractionated resurfacing really doesn’t suffer from any of these problems at all, or reduces the risk of these because we’re actually leaving a lot of the skin surface intact.

With any laser procedure around the face, one of the major issues afterwards is with infection, and particularly with the herpes virus reactivation of cold sores. So, if anyone even hints that they’ve had a cold sore in the past, I’ll put them on Valtrex or Famvir, one of those, Valtrex usually, before the procedure, so I think that’s quite important. Other than that, fractionated resurfacing is actually a very safe treatment because as I say, even though when you look at it you say, “Oh that skin’s very red, it’s been treated,” actually, 80% of the skin … depending on the area or the passing, 70 to 80% of that skin is actually intact.

So it makes it a very safe treatment, a lot safer in my hands than a lot of other treatments such as IPL, which might be considered a much less dangerous treatment, but I’ve had over the years, several IPL burns on people where I’ve had problem. Because it’s a full burn of a full area, I’ve had to treat it as a wound going forward. We have to manage that. I’ve really never had any problems like that with fractionated resurfacing. So actually, even though it’s an aggressive treatment, it’s actually a very safe treatment at the same time.

Trish: And gives good results quickly, I think.

Dr Bruce W.: It does. I mean, the original fractionated lasers that came around were based on the non-abrading wavelengths, because the history of laser resurfacing is people backed off from CO2 lasers because of some of these delayed healing, prolonged redness reactions. They went to less ablative lasers like RB YAG and Nd:YAG lasers. Then when the first fractionated lasers came around, the first Fraxel brand lasers, they were based around these less aggressive wavelengths. So people needed four to six treatments to get reasonable results with those early fractionated lasers, but then when the idea of fractionating a CO2 laser came around, so we have all the benefits of the CO2 laser with the increased heat and the tightening, but then we get the benefits of the fractionated laser with the safety and the quick healing. It’s a perfect combination. From my point of view, fractionated CO2 is the best skin rejuvenation treatment I have in my practise.

Trish: Yeah, I totally agree with it being one of the best skin therapy treatments, so I agree with that. I was going to ask you, just going back to the question about herpes, so if someone’s got the herpes virus in their system, you would treat them with something for that. How soon before they were having their treatment would you need to do that?

Dr Bruce W.: Okay, what I usually do, there is a pack made for cold sores of Valtrex which contains four, 1,000 mg tablets, so four large tablets. What I normally do with that is I give the patient a script for that, and I tell them to take one the night before, one in the morning of the resurfacing, one the evening after, and one the next morning. That gives them good coverage for a good 12 to 24 hours before, and 12 to 24 hours afterwards. That’s usually sufficient unless someone has a very problematic issue with cold sores, in which case, then I might put them on an actual course of Valtrex, starting them a day or two before and keeping them on it for a week afterwards, but that’s rare. Most people would just say oh, I get the odd cold sore now and then. I’ll just put them on the large pills and they do very well. I’ve only ever had one patient, when I first started out with laser resurfacing, who got cold sores, and she told me she hadn’t had one for 21 years. So anyone who ever mentions them after that, I put them on Valtrex, yeah.

Trish: Okay, so tell me, how long is the recovery? Say for example, I come and have it done tomorrow, can I go back to work? What’s the recovery like?

Dr Bruce W.: Yeah, what tends to happen is even though fractionated laser, we should go fairly lightly and do multiple treatments, when people get there, they go, “I’ve got a week off. I want you to go hard now.” So, I tend to treat people reasonably hard, and in that situation, they’ve got somewhere between five and seven days of real downtime, and another week of what I call social downtime. So real downtime is scaring children, don’t want to leave the house. That comes down to swelling around the eyes. So, when someone is swollen around the eyes, they look like they’ve been in an accident, or they’ve been beaten up, or something, and it has a visceral effect on another person when they look at them. That’s the real downtime.

After about three days, the swelling goes down and the skin peels. At that point, you can put make-up on, and at that point, you could actually go out from then on, but most people still feel a little self-conscious around them. So, by four or five days, it’s settling down significantly, but as I say, after three to four days, you can apply make-up. Then I’ve got what you call social downtime. That’s not looking scary, but running into a girlfriend on the street and her going, “Oh you’re pink. What have you been up to?” Now, if you don’t want to answer that question, you’ve got another maybe five to seven days of downtime after that as well, so coming up to 10 days to even 2 weeks, but you can cover that with make-up and provided you’re not with someone who’s going to quiz you very carefully about that, it’s usually you can function quite normally afterwards.

Both my wife and myself had laser treatment ourselves. We try and do it every year or two, on the 3rd of January this year because it’s was the only time we could take a week off. I don’t think my wife left the house for about five days. I must say I started … We live near a beach. I started going down and having a swim early in the morning about day three or four because I didn’t mind anyone seeing that I was a bit red in the face. My skin had healed to the point where I could swim by that stage, so gives you a general idea.

Trish: Yeah, everyone’s a bit different. So, when you did go to the beach, do you have to wear sunblock and keep it fully covered?

Dr Bruce W.: It was about eight in the morning when I was there, and absolutely, you have to wear sunblock, but I wasn’t wearing sunblock, and okay, this was just a quick swim. Basically no, saltwater’s not bad. As soon as I got home, obviously washed my face and put some Stratamed on there. I use silicone after resurfacing rather than Vaseline. I find it’s much better to use. I used to use Vaseline like everyone else, but I use the Stratamed products now, which I find great.

Trish: I love Stratamed. Do you use the new one, the Stratacel, at all after treatment?

Dr Bruce W.: That’s the one I use. I was using XIT, which was the radiation dermatitis one, but then they brought out Stratacel, which is basically the same product but it’s just been rebadged into something that’s not specifically for radiation dermatitis associated with breast cancer, which is what XIT was, but yeah, I’ve been using that same product for several years now. It’s fantastic.

Trish: Yeah, awesome. So, when would someone see the results? How long-

Dr Bruce W.: Okay yeah, you get an immediate peel of the skin. So by about a week, you can see a lot of the epidermis has lifted off and the skin looks clearer, but that’s by no means the real result. The collagen stimulation result takes many weeks to actually happen. So basically, there are four phases of healing. There’s the sealing over of the little surface wounds, which takes about two to three days. So, that’s the drying up and the peeling of the surface of the skin. Then there’s the settling inflammation, which is the redness coming out of the skin, which takes two to three weeks. Now, you may not be completely red for that period of time, but it takes about two to three weeks for that inflammatory phase to progress. It’s only after that period of time that collagen stimulation starts.

Initially, collagen’s laid down in a fairly random pattern, and then over a period of many months after that, you get collagen remodelling, which is the fourth phase of healing where some of that early collagen is resorbed and it’s laid out again in a more compact basket-weave pattern, so that goes on. So, the maximum result after laser resurfacing occurs about six months after the treatment. You would say that the skin starts to look really good afterwards at about six weeks after the treatment. So, I usually counsel the patient that they can actually seem to go backwards between week one and week three, because at week one, they’re still a little swollen. They’re plumped. They’ve had a peel and they’re thinking oh, this is quite good. My skin’s looking nice.

Between week one and week three, that redness, that swelling all goes out of there, and the skin’s quite dry at this stage too, because it’s suffered quite a bit of trauma, and they could seem to go a little bit backwards during that time. It turns around again at about week three. By week six, they’re actually starting to look. They’ve got that glow, and people are starting to comment on their skin. It’s not until three to six months afterwards that you’re really seeing the full effect of the treatment, at which time people come up and say, ‘Oh, you’re skin’s good. What product are you using?” It’s not the product you’re using now of course. It’s the laser you had six months ago that’s causing the skin to look good, not the products you’re using now.

Trish: Yeah.

Dr Bruce W.: So, that’s what happens. Even when you tell people that, they still don’t get their head around that delay, that long term collagen effect.

Trish: Yeah, that makes so much sense. Look, week one and week two, they’re not loving you. Week three, they’re like, “Oh my god, what have I done?” Week four, they’re like, “Oh, this is looking good. By week six, they love you.

Dr Bruce W.: Exactly.

Trish: Okay, all right. I always have this pause. So, how many treatments did you say you need? So, you do one and then-

Dr Bruce W.: Yeah. I mean, the hard thing is it’s all very well to say you need four treatments, or you need six treatments, but most people in the real world have a lot of trouble getting a week of downtime. It’s not an easy thing for them to do, so saying you need three or four trips … So, what I normally say to people is if you can get two treatments in a six month period, that would be what to aim for, because as I say, it’s rare for my patients to be able to line up, go through one of these treatments, and then another month or two later, take another week out of their lives and do another one.

It’s not a common … I can’t really do that myself, so what I tend to say to people is if you can do two treatments in a six month period, you’re doing pretty well realistically. Then obviously if you can do another treatment after that at some stage and then look on doing a maintenance treatment every one to two years after that, that’s a good general realistic protocol, as well as doing your Anti-wrinkle injections, as well as doing your fillers, so yeah.

Trish: All right, that’s if you want it, because you can just have this without having that sort of stuff too.

Dr Bruce W.: Of course you can. As we said before with relax, refill, resurface, reposition, the quality of the skin is the thing that brings across vitality, across health. That’s really what you’re trying to give here. I mean, with any of these treatments, we don’t forestall the ageing process. It’s the same with any of our medical treatments. We can’t really slow down ageing, but what we could do is prevent the degenerative diseases of ageing. Just like with the face, I try and balance features. So, I’m bringing back into keeping things that are starting to stand out as aged.

Certainly in the north beaches of Sydney, it’s the skin quality here where … Northern beaches of Sydney are the least obese area of Australia, so people are relatively health conscious. They’re exercising, and they’re relatively diet aware, but they tend to have a lot of sun damage because it’s a beach area and has been forever. They have a bit of volume depletion as well, for that reason as well, but skin’s one of the main things to fix up, yeah.

Trish: Yeah, I think it’s a similar demographic from where I live in Byron Bay.

Dr Bruce W.: Very much, yeah.

Trish: I’ve got to be the fattest person in Byron Bay for sure.

Dr Bruce W.: It’s the same in Manly. I mean, you walk around in Manly and you don’t see many at all. You go to different areas of Sydney and some of the country areas and the obesity epidemic is overwhelming. I’m not putting you in part of that, but you what I mean.

Trish: No, totally.

Dr Bruce W.: You’ve noticed, yeah.

Trish: Yeah, I like going to certain places out here or in Adelaide and I think oh my god, I look skinny. This is great.

Dr Bruce W.: Absolutely.

Trish: So, I know you said before, but you can use it on other areas of the body. So, you can use it on your neck, is that right?

Dr Bruce W.: You certainly can, and it produces fantastic results on the neck and chest and on the backs of the hands. It’s easy to do those treatments. You don’t have to use a lot of power. It really causes very nice rejuvenation. The neck’s quite hard to rejuvenate generally. Often people think they need tightening on the neck and chest when really what they’re looking at is sun damage and improving that quality of the skin. So the CO2 laser is great for that. The neck and … Sorry, I was meaning to say also specifically the chest and décolletage, because there’s a lot of sun damage on those areas.

While women have used make-up and potentially hats and sunscreens for quite a while, the chest has been a neglected area, and there’s often a high degree of sun damage. IPL really, it can help, but it doesn’t cut it on the chest sometimes. I mean, I’ve had IPL on the chest for a long time. You can get some improvement in the pigment. You can get some improvement in the redness, but it basically looks pretty much the same, whereas with the fractionated CO2, you can really improve the quality of the skin. You can get rid of a lot of that poikiloderma and that chicken skin look and really help that.

The back of the hands as well, another area that’s been neglected with people, with sunscreen over the years, has a high degree of sun damage. While we can get rid of the brown spots with IPL and that type of thing, really rejuvenating the skin, the fractionated CO2 laser comes into its own. You can go down the fingers. You can go all over the back of the hand. The downtime is minimal. People look like they’ve got these little mitts on for a few days afterwards and their hands get red for about 10 days, and the skin comes up really nicely on those areas. With those, you do need to do multiple treatments. You would do somewhere three to five treatments over a period of time, and you wouldn’t go as hard as you would on the face. It’s more resurfacing rather than a tightening as such.

Trish: Yeah, great. Basically, so I’ve got a few girlfriends who do have that décolletage damage from sun over the years. So, that’s perfect for that, is it?

Dr Bruce W.: Yes, it is.

Trish: Great.

Dr Bruce W.: I use the CO2 laser in preference. Otherwise, I’ll go to one of my vascular lasers or an IPL if it’s mainly just red and brown discoloration, but most of the time, there’s actually really substantial textural change on those as well, and the CO2 laser is great.

Trish: All right.

Dr Bruce W.: One thing also just to say, I’m sure that most of your listeners have heard this, but never put perfume on your neck. It’s the combination of perfume and the sun that causes what’s called poikiloderma, that red brown staining on the sides of the neck.

Trish: I didn’t know that.

Dr Bruce W.: Didn’t you?

Trish: No.

Dr Bruce W.: It should be written in big letters on perfume bottles as a health warning, or as a cosmetic health warning, I should say, because alcohol based perfumes are one of the causative factors of poikiloderma of Civatte, which is what we’ve been talking about, the chicken skinned staining on the side of the neck. So put the perfume down your cleavage, or on your wrists, or in your hair, but don’t put on the sides of your neck. It’s one of the bad places to put it, yeah.

Trish: Oh my god, I think I’m going to have to do an article just on that one.

Dr Bruce W.: Yeah, you should.

Trish: Absolutely. How do you spell that? What’s it called?

Dr Bruce W.: Poikiloderma P-O-I-K-I-L-O-D-E-R-M-A. Poikiloderma of Civatte is the proper name, C-I-V-A-T-T-E or something like that. It’s something like that. Yeah, that’s the proper dermatological name, but it’s that sun damage on the side of the neck that we’re talking about.

Trish: Alright, okay. I could talk to you all night, but I’m not going keep you all night, but I’m going to ask you one more question.

Dr Bruce W.: Sure.

Trish: So, who are the best candidates for this procedure? What I really want to know is can someone with acne use it, a teenager with acne or someone-

Dr Bruce W.: Not with active acne. So, if someone’s got active acne, then I’ll use a laser that’s going to pump a lot of heat deep in the skin to try and shrink the sebaceous glands down. So, I normally use a long pulse Nd:YAG laser in that situation, and you can get quite substantial shrinkage of oil glands using those laser treatments. So, that’s what I’ll do first, but if people have got acne scarring, and by that, I mean actual pitted scarring. I’m not talking about just red discoloration. If they’ve got red discoloration after acne, then I’ll treat them with IPLs usually or vascular laser, but if they’ve got pitted textural change, then the CO2 laser is great.

Absolutely I’ll treat them provided once again, the skin’s not too olive, and then we have to be more careful and just work around the pigmentation issues with the laser. So that doesn’t mean we can’t do it, but we have to work around it. In that situation, I will sometimes go to using radio frequency micro needling, where we put little pins into the skin and we pass the current down underneath the skin, because that causes less surface heating and is less likely to cause post inflammatory hyperpigmentation. So, I’ve got another option for acne scarring in the darker skinned people, but in fair skinned people, it works very well.

Other than that, who’s not a good candidate for it are smokers. Smoking unfortunately just causes lots of problems with damping down the collagen stimulation process. So, if someone tells me they’re a smoker, I’m very reluctant to do laser resurfacing on them. I mean, I’ll do Anti-wrinkle injections or fillers, but laser resurfacing where I’m relying on the skin healing to get a good result, it’s a hiding to nothing for me. So, that’s someone I don’t like to treat. People that have got active inflammatory conditions, medical conditions on their faces, I wouldn’t treat with the CO2 laser. So, you want someone who’s got relatively healthy skin. If someone’s got fine skin, it just means we go a lot lighter with the laser. If someone’s got heavier, more sebaceous skin, I can go deeper, but I can tailor the laser treatment.

When you were talking about downtime before, that’s when I do quite a firm treatment. We can, of course, just do very mild treatments with the CO2 laser where you’ve got one to two days of peeling and very little swelling as a freshener, but being a doctor ad being a medical practise, people tend to come more when they want the heavier, more aggressive from me.

Trish: Oh, that sounds great. I think you’ve answered all my questions. I could actually talk to you all night. I’ve got a million and one questions. So, that’s been really helpful especially for a lot of my girlfriends who are saying to me, “What can I do about this, and what can I do about that?” I think I don’t know, but that’s-

Dr Bruce W.: It’s a great treatment. Another treatment that I use quite a lot of is Photo Dynamic Therapy or PDT. The way I put it to patients is Photo Dynamic Therapy is a specific skin cancer treatment that has some cosmetic benefits, and fractionated laser resurfacing is a cosmetic treatment that has some skin cancer benefits. Once again, they’re not mutually exclusive, but if someone has a lot of actual sunspots, solar keratosis, on their face, then I will tend to treat them first with Photo Dynamic Therapy to mop that skin cancer up before I go to CO2 laser. If it’s the other way around and someone’s got more cosmetic deficits and maybe just a little skin cancers, then I’ll go for a CO2 laser. I can double pass or triple pass those little skin cancer areas and tend to get rid of those quite nicely at the same time, so yeah.

Trish: Oh fantastic. Well look, that’s just been such an eye opener for me. When you think you know everything and it’s like, oh okay, so that’s been really helpful.

Dr Bruce W.: That’s new stuff all the time.

Trish: Yeah, awesome. Well, thank you so much for taking the time to talk to us.

Dr Bruce W.: Yeah, my pleasure.

Trish: That’s been so much information. I think I’ve got about six articles I could do from just this. I like the four Rs. I’m going to use them for sure.

Dr Bruce W.: Yeah, it’s not original unfortunately. I heard that myself 10 years ago in some lecture, so yeah.

Trish: I like it.

Dr Bruce W.: Yeah, you can make it five Rs if you want, and the fifth one is retain, so relax, resurface, reposition, and then retain the results with maintenance therapy, so yeah.

Trish: Yes, it’s all about the maintenance. Well, thank you so much. I really appreciate your time.

Dr Bruce W.: Okay.

Trish: Guys and girls that are out there, if you’re looking for a laser guru, Dr Williamson is amazing. What I like about him, which you’ll like as well, is he will actually treat what you actually want done, rather than using one particular device to do everything, so, that’s really impressive. So, if you want to get in contact with Dr Williamson, you can either send me an email to, or otherwise Google SkinSmart. Is that right?

Dr Bruce W.:, that’s right, yeah. SkinSmart Medical Services or is our website.

Trish: Awesome, fantastic. Well, thank you so much.

Dr Bruce W.: Thanks a lot Trish. It’s been a pleasure, bye.

Trish: Okay, thanks a lot, bye.


Trish is a plastic surgery blogger. She is passionate about wellbeing, health and beauty, and doesn't mind a little bit of 'help' from the amazing cosmetic and beauty procedures that are available today. Trish spends her days talking to women and men who are looking for suggestions and advice on procedures that are available to them. Cutting through the sales pitch and hype, a down-to-earth response on general information is what you will get.

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