This Update on Lasers is a practical clinical review of the newest technologies and techniques. Although the contributing authors have been involved in laser research, they also are engrossed in the day-to-day practice of laser surgery. Whether one has just begun to work with lasers or is a fellowship- trained laser surgeon, each article offers something for the practitioner. In the following pages, an overview of some of these technologies is discussed within the context of how we currently integrate them in our practice. Combination Treatments and Optimization of Potential An important concept in laser and cosmetic surgery is the optimization of potential. This concept relates to the creative integration of devices and other interventions for an individual patient. For instance, the long pulsed 755-nm alexandrite has great potential. By understanding the respective absorption coefficients for melanin and bloods as well as clinical end points, the 755-nm laser can be optimized to treat a wide range of conditions. It is quick and effective for laser hair reduction, pigmented lesions, and selected vascular lesions— namely port wine stains, telangiectasia, and vascular malformations (Fig. 1). Although “cookbook” settings are reassuring for the novice practitioner, simply using a given manufacturer’s laser setting often is inappropriate. What is more important in optimizing a device’s potential is recognition of clinical end points such as Purpura in a port wine stain (PWS) or graying and subsequent darkening of a Lentigo. A test site is advisable, such that the physician can adjust the cooling and fluence until a patient-specific desired end point is achieved. The optimization of potential concept should be considered when choosing among lasers and light devices. There are 3 main targets that the laser surgeon can affect: dyschromias, making up the first 2 (brown pigmentation and red telangiectasia) and rhytides. These “three uglies” can be approached with various wavelengths. Optimizing the potential efficacy and safety for each individual patient requires the use of a multiprocedural approach. Fractionated Midinfrared Nonablative Lasers As midinfrared (mid-IR) fractionated devices have become more popular, their capabilities and limitations have become more clearly defined. Dr Bogle does an excellent job of reviewing the literature and discussing the role of these lasers in clinical practice in the article titled “Fractionated Mid-Infrared Resurfacing” on page 252. As with many newly introduced technologies, the fractionated devices, pioneered by Reliant’s Fraxel (Reliant Technologies, Mountain View, CA), have received enthusiastic support from the industry as well as the dermatologic laser literature. In comparison with some previous laser fashions of the day, many initial claims have stood the test of time. These devices work most consistently in reducing dark lentigines and fine facial lines. More importantly, mid-IR fractional lasers offer a degree of operator independence with respect to outcomes, as well as allowing for user-titratable downtimes. Ablative options before 2004 presented a greater permanent scarring risk, and greater operator skill and familiarity with laser mechanics and laser–tissue interactions (LTIs) were required to avoid complications. With the advent of fractionated devices, the safety and effectiveness profiles have improved enough such that providers with less LTI knowledge and experience can treat fine facial textural irregularities with minimal risk. As Dr Bogle points out, there are many ways to “tweak” the mid-IR devices to obtain even greater results and to treat other conditions that are more operator dependent, including melasma, striae distensae, periocular rhytides, and acne scars. Although we offer fractionated laser treatment as a monotherapy, we often combine fractionated treatment with a 532-nm potassium-ttitrium-phosphate (KTP) or 595-nm pulsed dye laser (PDL), facial fillers, or q-switched lasers. Patients disappointed with previous fractional laser therapy often have been poorly educated on expected outcomes. Most frequently they complain of residual lentigines. In these patients, we often “finish” the treatment by simply using either long pulsed or q-switched visible light or localized ablative techniques (Fig. 2). However, these goals and potential outcomes and risks should be thoroughly discussed with the patient so that he or she understands the relationship among downtime, number of treatments, and efficacy. The same is true for residual rhytides. Patients often state that a previous provider promised resolution of periocular and perioral lines after a set of 4-5 fractional nonablative treatments. Laser surgeons who have used these devices on a consistent basis know that periocular and perioral rhytides are resistant and require more aggressive interventions. Furthermore, patients must understand the differences between dynamic and static lines and the range of options for improvement. Adjunctive procedures such as fillers or botulinum toxin will enhance the results of laser. Finally, although devices can improve rhytides consistently, none will consistently eliminate them. Overall, the mid-IR fractionated devices offer consistent results with less operator dependence and an acceptable downtime. Although the development of the fractionated CO2 laser is promising, the mid-IR fractionated devices retain the advantage of less downtime. Fractionated Ablative Lasers The new generation of fractionated ablative lasers allows treatment of more refractory facial irregularities such as acne scars and perioral and periocular rhytides. In our limited experience, we have determined that patients who are treated an Axis I or Axis II diagnosis but more commonly will have traits of personality disorders or “routine” anxiety or depression. Those who provide cosmetic surgical care know that these patients can be difficult when an unexpected outcome occurs. For example, use of the same education and bedside manner with a patient with borderline traits as in a patient with obsessive-compulsive traits can result in frustration for both physician and patient. Although the expected outcome for the physician may have occurred (ie, dramatic reduction in facial telangiectasia) the outcome might be interpreted as a failure (ie, obsession with the remaining facial telangiectasia or discontent with the downtime). Furthermore, any patient with a previously diagnosed personality disorder should be carefully evaluated, and the surgeon should consider using a multispecialty approach that includes a mental health provider. Medical assistants and nurses can be instrumental in creating a positive experience. Patients and staff assignments should be choreographed so that there is optimal pairing of educator and patient. The physician should consider carefully the staff impressions of the patient’s “attitude.” Those impressions can direct the patient toward the most appropriate procedures. Conclusions We are in an exciting era of laser and light therapy in dermatologic surgery. Technologic advances continue to refine the delivery of various wavelengths more effectively, safely, and predictably. However, optimizing the potential of both the settings of each individual laser, as well as combining lasers and other treatment modalities, remains the laser surgeon’s objective. Addressing the individual patient’s needs, goals, and personality connects the science of treatment with the care of our patients. Acknowledgment Dr. Uebelhoer would like to thank Dr. George Martin and his MauiDerm 2008–Advances in Cosmetic and Medical Dermatology meeting. The seminar was instrumental in providing key details for the content and structure of this edition