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adiofrequency, and Light-Based Deviceslizabeth Dawson, MD, Andrea Willey, MD, and Ken Lee, MD

Medical and esthetic indications and demand for nonablative laser and light-basedtreatments are increasing. Although these are generally safe procedures, laser practi-tioners should be aware of potential complications that may be associated with therapy.An adverse event may be defined as any undesirable effect, even if expected, thatoccurs with laser treatment. These adverse events can be related to patient factors,professional errors, common side effects, and more serious complications. A variety ofproviders, including nondermatologists, perform laser treatments and must be aware oftherapeutic outcomes as well as potential complications after laser surgery. Clinicalindications for nonablative laser treatments, common side effects, and more seriousadverse events will be reviewed in addition to treatment and prevention of thesepotential complications.Semin Cutan Med Surg 26:15-21 © 2007 Elsevier Inc. All rights reserved.

KEYWORDS laser complication, adverse event, side effect, outcome

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he use of laser, light, and radiofrequency energy devicesis rapidly evolving for both medical and esthetic indica-

ions. Although these treatments generally are safe andell-tolerated, the complexity of procedures and potential

or adverse events should not be underestimated. A basicnderstanding of laser physics is essential for the safe andffective operation of these devices. The theory of selectivehotothermolysis revolutionized the safety and efficacy ofonablative laser therapy by allowing thermal injury to bepatially confined to the target chromophore.1 In addition,he development of tissue-cooling methods have greatly ex-ended the therapeutic profile of modern laser practice.2

ore recent advances in optical technology have expandedhe principles of selective photothermolysis to take advantagef less selective tissue heating.3 Complications associatedith these new devices may not be as predictable or readilyetectable by observing immediate tissue reactions. Despiteptimizing treatment parameters for a specific clinical indi-ation and patient factors, a provider may nevertheless en-

epartment of Dermatology, Oregon Health and Science University, Port-land, OR.

ddress reprint requests to Ken Lee, MD, Department of Dermatology, OregonHealth and Science University, Department of Dermatology, 3303 S.W.

tBond Avenue, Portland, OR 97239. E-mail: leeken@ohsu.edu

085-5629/07/$-see front matter © 2007 Elsevier Inc. All rights reserved.oi:10.1016/j.sder.2006.12.003

ounter adverse events due to device failure and should beware of this potential source of error.

An adverse event constitutes any undesirable effect, even ifxpected, that occurs with laser treatment. Even in the handsf physicians with high levels of training and expertise, com-lications occur during and after laser treatment and shoulde anticipated and managed properly. This article will out-

ine clinical indications for nonablative laser treatments andhe mechanisms of tissue injury that result in both common,xpected side effects and serious adverse events. Finally, weill discuss ways to minimize and treat these potential com-lications.

atient Factorsthorough discussion with a patient is necessary preopera-

ively to provide detailed information regarding the plannedreatment, potential benefits and side effects, treatment alter-atives, and cost. Adequate patient consultation is necessaryo promote realistic expectations, ascertain the patients’ ac-eptance of potential side effects, and discuss the possibilityf treatment failure or recurrence of the condition beingreated. A provider should ideally offer the patient photo-raphic examples of potential treatment complications. Em-hasis on postoperative care, including ice packs, photopro-

ection, and clinical follow-up are essential to minimize

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16 E. Dawson, A. Willey, and K. Lee

nwanted outcomes. Proper documentation of the patientonsultation, consenting process, and preoperative photo-raphs are recommended.

Patient factors can markedly affect the outcome of laserurgery and should be evaluated before initiation of therapy.hese include the indication for treatment, location of the

esion, Fitzpatrick skin type, presence of a suntan, andlanned outdoor activities. Patients with darker skin typesre more likely to have postoperative dyspigmentation andarrant conservative treatment with lower fluence, longeravelengths, and adequate tissue cooling. Performing test

pots 2 weeks before initiating treatment and observing fordverse side effects can be valuable in these patients to reducehe risk of complications. The patient’s medical history, in-luding infections (ie, herpes simplex virus), connective tis-ue disease (a marker of photosensitivity), or vascular abnor-alities may be contraindications to laser surgery. Other risk

actors include a history of keloids or abnormal scarring,ostinflammatory hyperpigmentation, and a family history ofigmentary abnormalities. Review of the patient’s medication

ist and allergies is essential to avoid or minimize side effectsuch as bleeding, increased bruising, delayed healing, scar-ing, pigment alteration, or localized chrysiasis.4,5 Potentiallyroblematic medications include retinoids, minocycline,old, amiodarone, warfarin, acetylsalicylic acid, niacin, non-teroidal anti-inflammatory drugs, and vitamin E. Finally, aaser practitioner should establish whether the patient hasad any previous cosmetic surgeries or procedures that may

nterfere with the laser treatment or alter tissue response.

rofessional Errorsrofessional errors may result from inadequate training,

mproper laser operation, insufficient documentation, lim-ted patient information, incorrect diagnosis or treatment in-ication, and failure to perform test treatments. Strategies tobviate some of these preventable adverse events are suc-inctly reviewed by Greve and coworkers6 and are beyondhe scope of this article. Many complications can be avoidedr minimized by carefully monitoring the tissue reaction tohe laser treatment. An experienced laser surgeon can usuallyecognize an immediate adverse response such as tissue whit-ning or graying which indicates thermal injury and requiresrompt discontinuation of treatment and review of devicearameters and function.Importantly, many laser practitioners are not dermatolo-

ists and may erroneously treat a pigmented lesion that is inact a melanoma, pigmented basal cell carcinoma, or atypicalevus. A laser practitioner should be aware of the potentialor misdiagnosis of malignant skin lesions and the necessityf dermatologic evaluation of pigmented lesions. Finally,trict laser safety is important to protect the patient, provider,nd potential bystanders during laser operation. Proper ad-inistration of laser surgery requires education and practical

raining to minimize the risk of ocular and cutaneous injury,

re, and electrical hazards. o

omplications by Indicationascular Lesionscquired and congenital vascular lesions such as facial telan-iectasia, port wine stains, infantile hemangiomas, and legeins are frequent indications for laser treatment. Lasers andight sources commonly used to treat vascular lesions includehe flashlamp-pumped pulsed-dye laser (PDL; 585-600 nm),ong-pulsed Potassium Titanyl Phosphate (KTP; 532 nm),lexandrite (755 nm), Neodymium Yttrium Aluminum Gar-et (Nd: YAG; 1064 nm), and broad-spectrum intense pulsed

ight (IPL) sources. IPL devices target both vascular and pig-ented lesions and will be discussed separately. Vascular

pecific lasers target intravascular oxyhemoglobin, transfer-ing thermal energy to the surrounding blood vessel wall.arameters such as wavelength, pulse duration, and fluencere optimized to decrease unintentional tissue injury. If theulse duration of the laser exceeds the thermal relaxationime of the target chromophore, thermal diffusion and tissueamage may occur. Historically, treatment of vascular lesionsith the continuous-wave argon laser, argon-pumped tun-

ble dye laser, copper vapor, and copper bromide lasers wererequently associated with adverse effects such as scarringnd permanent dyspigmentation. These complications areow significantly reduced with newer pulsed-dye lasers thatperate with extended pulse durations and incorporatedryogen spray cooling to minimize collateral tissue injury.ecause of its superior safety and efficacy profile, the PDL ishe most commonly used laser to treat vascular lesions.

Purpuric parameters often are needed to effectively treatascular lesions such as hemangiomas and port wine stains.purpuric response is a frequent side effect of treatment and

ccurs most often with short pulse durations that cause va-orization and rupture of superficial vessels and extravasa-ion of red blood cells. The use of extended pulse durationsay prevent significant purpura, however these subpurpuricarameters often require multiple treatments, pulse-stack-

ng, and multiple passes to achieve the targeted clinical end-oint. Common side effects include transient erythema anddema. Edema typically resolves within a few days of laserreatment but can be significant, particularly with pulse-tacking and treatment with more than 250 pulses.7 Post-reatment edema may be considerable in periocular areas.

anagement of purpura is usually supportive with applica-ion of ice packs, topical corticosteroids, and petrolatum iflceration occurs. Postoperative edema and erythema isreated with similar supportive measures as well as head ele-ation; more severe cases may benefit from a short course ofral corticosteroids.In addition, treatment of vascular lesions with the PDL will

ften produce a reticulated pattern due to the Gaussian dis-ribution of energy within a laser pulse. Overlapping pulsesy 18% can minimize this “honeycomb” appearance, how-ver even with diligent pulse overlapping, both reticulateattern erythema and dyspigmentation can occur (Fig. 1).8

Because of its close approximation to the peak absorption

f hemoglobin, the KTP laser (532 nm) is well suited for the

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Adverse events and nonablative laser and light-based treatments 17

reatment of superficial telangiectasia using short millisecondulses. Transient linear crusting followed by temporary dys-igmentation is a common side effect after KTP laser treat-ent and typically resolves within a week of therapy.9 Appli-

ation of petrolatum to erosions is useful to expedite woundealing.Transient or permanent dyspigmentation can follow treat-ent of vascular lesions with many laser and light devices

ecause melanin coabsorption occurs throughout the visiblend near-infrared spectrum (Fig. 2). Postinflammatory hy-erpigmentation is typically reversible although it may lastor months, particularly in patients with darker skin types.or this reason, treating a spot and observing the patients’issue response four to six weeks later can be helpful to gaugehe potential for dyspigmentation. Patients should be advisedo avoid excessive sun exposure postoperatively and applyunscreen diligently.

Ulceration, scarring, and textural changes are rare withroper patient selection and appropriate treatment parame-ers. Observing the immediate tissue reaction for vessel co-

igure 2 Hyperpigmentation after treatment with a 595-nm pulsed-

igure 1 Postoperative hypopigmentation after treatment with a95-nm pulsed-dye laser. (Color version of figure is available on-

ine.)

aye laser. (Color version of figure is available online.)

gulation and epidermal changes is essential to monitor tis-ue response. Striking erythema or graying of the epidermis issign of excessive thermal damage. Adequate cooling is es-

ential to minimize damage to surrounding tissue and theotential for scar formation. In addition, dermal depressionsave been observed several weeks to months after treatment of

arger facial vessels or refractory alar telangiectasia (Fig. 3).10

hese lesions may resolve spontaneously and can benefitrom gentle massage. In more severe cases, nonablative laserreatment or cosmetic fillers may improve textural appear-nce.

Because of their deeper optical penetration, long-pulseded and near-infrared lasers such as the Alexandrite (755 nm)nd Nd: YAG (1064 nm) are commonly used to treat largeracial vessels and leg veins. Although venous ectasias on theower extremities are most effectively treated with sclerother-py, vascular lasers are useful for patients who are not can-idates for this procedure. Because absorption of hemoglo-in is greatly reduced at longer wavelengths, high fluencesre required to achieve vessel coagulation and cooling isherefore essential. With the use of long pulse durations, bothre and parallel cooling are applied. In the event of coolingailure significant ulceration can occur. The use of overlyggressive treatment parameters and pulse stacking shoulde strictly avoided.More complex vascular lesions such as hemangiomas,

hick port wine stains, and venous malformations may ben-fit from treatment with infrared lasers such as the Nd: YAG1064 nm). Because of great variability in the threshold forhermal injury within these complex vascular malformations,aser treatment should be limited to experts who are familiarith the complicated morphology of these lesions.10,11 Com-ination laser devices that can deliver multiple wavelengthsre being developed and will likely improve the efficacy andafety profile for treatment of these complex vascular le-ions.12

enign Pigmented Lesionsolar lentigines, ephelides, and flat seborrheic keratoses

igure 3 Dermal depressions on the nasal alar crease after treatmentf telangiectasia with a long-pulsed 532-nm KTP laser. (Color ver-ion of figure is available online.)

re benign pigmented lesions commonly treated with Q-

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18 E. Dawson, A. Willey, and K. Lee

witched lasers. The importance of correct diagnosis of pig-ented lesions before laser treatment cannot be overempha-

ized. Evaluation by a dermatologist before a laser procedures recommended to verify that the pigmented lesion of con-ern is not malignant. The lasers commonly used to treatenign pigmented lesions operate in the Q-switched nano-econd range and include the Ruby (694 nm), frequency-ouble Nd: YAG (532 nm), and Alexandrite (755 nm). Byirtue of being Q-switched, thermal damage is largely con-ned to pigment within melanosomes, minimizing collateralissue injury.

Expected side effects after treatment with pigment-specificasers include immediate, superficial tissue whitening fol-owed by mild erythema and edema. Vesiculation and crust-ng may be observed within 1 to 2 days; healing is usuallyomplete by 10 to 14 days.13 More severe blistering can occurith use of high fluences or in the presence of dense pigmen-

ation. Application of petrolatum ointment is necessary forptimal wound healing and can minimize scar formation inhe case of significant blistering.

Transient postinflammatory hyperpigmentation is com-on after an erythematous tissue response and typically

mproves over time. Treatment options include topicalleaching creams or chemical peels for more severe facialyperpigmentation. Persistent postoperative hypopigmenta-ion can occur with the use of high fluences and may improvever time although it is often refractory to treatment.Scarring can occur with the use of aggressive treatment

arameters and poor patient selection. When treating pig-ented lesions, it is advisable to initially use the lowest ef-

ective fluence and titrate upwards based on immediate tissueesponse. Stacking pulses and multiple passes over a targethould be avoided with Q-switched lasers.

In general, the risk of side effects with pigment-specificasers increases with the relative absorption of melanin for apecific wavelength. Because of greater melanin absorption,listering and dyspigmentation can be more prominent withhe 532-nm frequency-doubled Nd: YAG and the 694-nmuby laser. These lasers should be used cautiously in deeplyigmented lesions and avoided in patients with darker skinypes or suntanned skin. Conversely, the 1064-nm Nd: YAGas a lower incidence of side effects and can be safely used inore heavily pigmented skin.

attoo Pigmentrofessional, amateur, cosmetic, and traumatic tattoos alsore effectively treated with Q-switched pigment-specific la-ers. Generally therapy is well tolerated, with similar sideffects as those discussed with treatment of benign pig-ented lesions. Patients typically need multiple laser therapy

essions depending on the quality of the tattoo (professionalypically requiring more than amateur), age of the tattoo, andigment composition. It is essential to avoid treating a patientith suntanned skin because a pigment-specific laser cannotiscern constitutional pigment from exogenous tattoo pig-

ent. a

Red and near-infrared Q-switched lasers (Alexandrite55 nm, Ruby 694 nm, Nd: YAG 532 and 1064 nm)re effective for lightening black pigment. The Alexandrite755 nm) and Ruby (694 nm) lasers are well-suited for tar-eting green pigment while green laser light (Nd: YAG32 nm) is the best choice to treat red, orange, and yellowattoo inks. Incomplete removal with residual pigmentations not uncommon with tattoo treatment. Particular tattooigments are more difficult to treat with laser devices and

nclude those with turquoise blue, purple, and yellow inks.attoos previously treated with chemical peels or salabrasionre potentially more resistant to laser removal secondary tobrosis and scarring. Furthermore, in some tattoos pigmentverlying the original tattoo ink may obscure the originalattoo colors and present a challenge for treatment because ofhe density of pigment in the skin. Lastly, IPL devices andther millisecond lasers lead to scarring and should not besed to for tattoo removal (Fig. 4).It is important to do a test spot when treating tattoos to

erify that the fluence being used is not disproportionate tohe amount of tattoo pigment. Using excessive fluence canesult in edema, blistering, bleeding, crusting, and possiblycarring. For this reason, treatment should start with theowest fluence and largest spot size and be titrated accordingo treatment response.14 In the event of postoperative crust-ng and erosions, petrolatum ointment is essential to promoteound healing and minimize scarring. Any blisters the occur

fter treatment should be left intact. After laser treatment,hotoprotection is essential to prevent postinflammatory hy-erpigmentation and minimize the potential for suntanningkin before subsequent laser treatment. When treating largextremity tattoos, it is important to be aware of the number ofulses delivered. Excessive pulse quantity per treatmentession has resulted in closed-compartment syndrome ofhe upper extremity requiring decompressive volar fasci-ctomy.15

Dyspigmentation is a common adverse event and shoulde expected after multiple treatments with pigment-specific

asers. Hypopigmentation is more likely to be permanentecause repeated laser treatments will decrease constitutionaligment as well as residual tattoo pigment. Postinflammatory

igure 4 Treatment of a tattoo with a long-pulsed hair removal laseresulted in hypertrophic scarring. (Color version of figure is avail-

ble online.)

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Adverse events and nonablative laser and light-based treatments 19

yperpigmentation is common, particularly in dark skinnedndividuals, but is usually transient. Use of an appropriateatio of fluence to pigment density can minimize dyspigmen-ation.

Complications unique to laser treatment of tattoos includexidation, allergic, and ignition reactions. Oxidation of tattoonk results in irreversible, immediate pigment darkening ofattoos that contain iron oxides or white ink. The paradoxicalarkening is secondary to a chemical reaction reducing ferricxide or titanium dioxide that is present in red or whiteigment, respectively. Performing a test spot is imperative tovaluate the candidacy of the tattoo for laser treatment anddvise the patient accordingly. Cosmetic tattoos or multipig-ented tattoos that contain white ink should not be treated.reatment with the Nd: YAG laser may lighten the oxidizedigment, however these darkened tattoos are typically refrac-ory to laser therapy. Alternatives for tattoo removal includeurgical excision, dermabrasion, and ablative laser treatment.

Various types of hypersensitivity reactions to tattoo inkave been described. Laser fragmentation of pigment-con-aining cells liberates tattoo pigment extracellularly where itas the potential for increased antigenicity. Clinically a pa-ient may manifest erythema, dermatitis, urticaria, or a local-zed granulomatous reaction. Topical or intralesional steroidsan be used for symptomatic relief. Laser tattoo removalhould not be attempted in patients with a history of hyper-ensitivity, redness, or swelling associated with tattoo ink dueo risk of exacerbating an allergic reaction and potential forystemic hypersensitivity and anaphylaxis. If the patient has aistory of systemic allergic reaction to tattoo pigment, treat-ent options include mechanical removal of the tattoo with

urgical excision or laser ablation. In the presence of hyper-ensitity, oral corticosteroids are given before and after abla-ive methods of removal and resuscitative equipment shoulde available if needed. Evaluation by an allergist before treat-ent may be recommended in some cases.Ignition of gunpowder is a rare but potential complication

ith firecracker or traumatic tattoos. Laser ignition may re-ult in fire, explosion, and scarring.16 There may be a poten-ial cancer risk from chemicals released as ignition byprod-cts.17

hotoepilationaser reduction of unwanted hair is a popular, generallyell-tolerated procedure. Lasers within the red and infrared

ange, including the long-pulsed Ruby (694 nm), Alexan-rite (755 nm), Diode (810 nm), Nd: YAG (1064 nm), inddition to broad-spectrum intense-pulsed light sources aresed for photoepilation. Long pulsed lasers target melaninithin hair follicles causing thermal damage to the follicle

nd temporary miniaturization of the hair shaft.18

When a patient presents for laser hair removal, it is impor-ant to discuss realistic expectations after therapy. Responseo treatment depends on the hair color, shaft diameter, skinype, and hormonal factors. The ideal candidate for photo-pilation is an individual with fair skin and dark, coarse hair.

he efficacy of laser hair removal is greater with the use of m

igher fluences.18 However, the inappropriate use of exces-ive fluences is associated with an increased risk of compli-ations. Thus, optimal results of photoepilation depend onoth practitioner skill and knowledge of device operation.Common side effects with photoepilation include mild

ain with treatment, erythema, and perifollicular edema. Se-ere pain can be an indication of excessive fluences or inad-quate cooling. Dyspigmentation, blistering, and even scar-ing may also occur and are more common in patients witharker skin types, a suntan, or when lasers in the red spec-rum are used. The Nd:YAG is the preferred laser for treat-ent of dark skinned individuals because of its longer wave-

ength, deeper penetration, and reduced melanin absorption.owever, permanent hair removal is less common with

onger wavelengths and repeated treatments are usuallyeeded.Burns resulting from cooling failure associated with both

perator error and device failure have been described. Arcu-te-shaped burns may result from angling of the hand pieceuring treatment of curved surfaces leading to misalignmentf the cryogen spray relative to the laser spot.19 It is importanto keep the laser hand piece perpendicular to the skin, par-icularly when treating curved areas such as the face and legs.dditionally, annular burns may occur with the use of insuf-cient cryogen spurt duration for a given spot size. A mini-um spurt duration of 40 milliseconds is recommended forspot size of 15 mm, and 50 milliseconds for an 18-mm spotize.19,20 Heating of accumulated debris on the guidepost maylso lead to ring-shaped burns.

Less common and poorly understood complications ofhotoepilation include reticulate erythema, paradoxical hy-ertrichosis, and urticarial-like plaques. Reticulate erythemaas been described after hair reduction treatment with theiode laser. This uncommon side effect is poorly understoodut may result from interaction between the laser energy andhe underlying vasculature. Patients with a history of pernior collagen vascular disease may be at higher risk of thisomplication.21 Paradoxical hypertrichosis has been de-cribed after photoepilation with both lasers and IPL devicesnd may be more common than previously believed.22,23 Ur-icaria-like plaques have occurred after laser hair reductionnd may be pruritic and persist for days to weeks. The etiol-gy of these lesions is not understood but symptoms maymprove with the use of topical corticosteroids and oral an-ihistamines.

onablative Resurfacingompared with ablative techniques, nonablative resurfacing

s less invasive with shorter recovery time and fewer adverseffects. Several devices are currently used to achieve im-rovements in skin texture and laxity, including visible, near

nfrared and mid-infrared lasers, radiofrequency energyources, intense pulsed light devices, and combinations ofhese modalities. These devices are thought to stimulate der-al collagen remodeling and rely on tissue cooling to mini-

ize epidermal damage.

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Proper technique is essential with these devices because ofhe absence of a visible epidermal reaction on which to gaugereatment response. Patient feedback on pain sensation ismportant during the procedure to guide treatment parame-ers and should be observed closely. Aggressive anesthesia is aisk factor for adverse events because patient pain perceptionay be blunted and excessive thermal damage may occur.Common side effects after nonablative skin resurfacing

nclude moderate erythema and edema. These usually re-olve within 1 to 2 days of treatment. Complications primar-ly result from overheating tissue with excessive energies ornadequate cooling. Adverse events include severe pain, dys-igmentation secondary to epidermal injury, blistering, andcarring. Treatment with appropriate parameters as well asre, parallel, and posttherapy tissue cooling can minimizehese complications. Management of these adverse outcomess largely supportive.

Radiofrequency (RF) tissue tightening is a unique nonsur-ical treatment of skin laxity and tissue contour. Controlledeat modification of collagen stimulates a wound healingesponse with immediate contraction of collagen fibrils andelayed formation of new collagen. Late side effects such asutaneous depressions can occur weeks or months postoper-tively and result from overheating of adipose tissue andbrous septae with monopolar RF devices. Caution must besed when treating over bony prominences or thin skin suchs the forehead and temples; drawing skin away from bonyrominences during treatment is recommended to minimizeontour irregularities. Treating with lower fluences and mul-iple passes is advised to decrease the risk of adverse events.24

ild dermal depressions often resolve spontaneously overime. More severe contour irregularities and scarring maymprove with surgical subscision, autologous fat transfer, orosmetic fillers.24

Near and midinfrared lasers target water surrounding der-al collagen, stimulating dermal remodeling to improve the

extural appearance of acne scarring and fine lines from pho-oaging. Epidermal cooling is crucial to decrease blisteringnd the risk of scarring. Excessive “bulk heating” of the der-is without visible clinical endpoints may lead to cata-

trophic burns. Patients should be counseled regardingeasonable expectations for treatment outcome. Maximalermal remodeling and textural changes usually peak 6onths after treatment. These changes may be subtle and in

ome patients clinically inapparent.Fractional resurfacing is a promising new laser used to

reat fine lines, dyspigmentation, and some forms of scarring.he fractional resurfacing device creates small columns ofpatially confined thermal injury called microscopic treat-ent zones (MTZ) that specifically spare surrounding tissue.ninjured epidermis and dermis that surrounds MTZs pro-ote healing while intact stratum corneum overlying theTZ serves as a biologic dressing. Common side effects dur-

ng treatment include mild pain, erythema, and edema. Inddition to topical anesthesia, use of air cooling and loweruences can minimize intraoperative discomfort. Posttreat-ent erythema and edema are typically mild and usually

esolve over a few to several days but may last longer.25 Al- v

hough anesthesia is necessary for treatment, caution is war-anted to monitor the dose and duration of topical lidocainepplication to avoid toxicity from systemic absorption.

Complications with fractional resurfacing can occur withigh treatment densities that result in confluent areas of ther-al damage without intervening zones of healthy tissue toromote wound healing. Immediate tissue whitening resultsrom excessive treatment densities and may result in perma-ent hypopigmentation.10 Similar to other lasers, more se-ere adverse outcomes can occur with the use of excessiveasses or high fluences.

ntense Pulsed Lighthe intense pulsed light system emits noncoherent broad-and light in the range of 515 to 1200 nm. Indications for IPLreatment are numerous and include pigmented and vascularesions, photoaging, and photoepilation. Complications as-ociated with earlier IPL devices are much improved with these of dichroic filters and incorporation of cooling within theandpiece. The broad range of wavelengths used in IPL de-ices increases the potential for side effects associated withbsorption of epidermal pigment. Thus, even with the use ofew devices, proper application of cooling devices is essen-ial.

Common side effects after treatment with IPL include mildostoperative erythema and edema. More serious superficialurns and scarring can occur with aggressive treatment pa-ameters. These can be minimized by the use of appropriatereatment settings, cooling methods, and proper patient se-ection. Patients should also be advised regarding photopro-ection with sun avoidance and sunscreen to minimizeostinflammatory hyperpigmentation after an erythematousreatment response. Because of the potential for competitionetween different chromophores with IPL systems, this de-ice should be used cautiously in darkly pigmented and sun-anned skin. Complications arising from IPL devices are sim-lar to lasers, however with a larger spot size, the inability toisualize immediate tissue effects with contact cooling tips,nd the broad spectrum of light exposure, there is potentialor serious thermal injury if used improperly (Fig. 5).24 Be-

igure 5 Scarring and dyspigmentation after the use of aggressivereatment parameters with an intense pulsed-light source. (Color

ersion of figure is available online.)

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Adverse events and nonablative laser and light-based treatments 21

ause IPL devices do not operate in the nanosecond pulseuration range they should not be used for tattoo removal ashis results in significant thermal tissue injury and scarring.

Care should be taken to maintain slight overlap betweenulses to ensure confluent treatment of the target areand avoid “skip” (untreated) areas. These “skip” areas mayeave a footprint of dyspigmentation in contrast to neighbor-ng treated areas (Fig. 5). Transient neurologic sequelae areotential anecdotal complications after IPL treatment of skinverlying bony prominences, particularly in elderly patientsith thin, atrophic skin. Temporary neuropraxia may beinimized by decreasing the energy delivered by the IPL

ystem in these high-risk areas. In addition, the use of con-ervative treatment parameters and diligent cooling is pru-ent when treating the neck and genital skin, which is typi-ally thinner and more darkly pigmented.

ummaryurrent lasers, RF devices, and light-based sources areidely used by many practitioners with varying degrees of

aser training and experience. Most Q-switched and pulsedasers adhere to the concept of selective photothermolysis inhich thermal injury is largely spatially confined to specific

issue chromophores and thermal damage to surroundingissue is minimized. Recent advances in optical technologynclude devices that do not strictly adhere to principles ofelective photothermolysis, targeting chromophores that areot spatially confined such as water surrounding collagen,s well as noncoherent light and energy sources. With allaser and light-based treatments, adequate cooling and epi-ermal protection are crucial to minimize and prevent ad-erse events. Although these modalities are generally safe,ncorrect or overaggressive use of any laser or light device hashe potential for irreversible complications such as scarringnd permanent dyspigmentation. Operator education andxperience are essential to master the skills to deliver appro-riate treatment, prevent adverse outcomes, and manageostoperative complications.

eferences1. Anderson RR: Lasers in dermatology—a critical update. J Dermatol

27:700-705, 20002. Nelson JS, et al: Dynamic epidermal cooling during pulsed laser treat-

ment of port-wine stain. A new methodology with preliminary clinicalevaluation. Arch Dermatol 131:695-700, 1995

3. Alam M, Dover JS, Arndt KA: Energy delivery devices for cutaneousremodeling: Lasers, lights, and radio waves. Arch Dermatol 139:1351-

1360, 2003

4. McBurney EI: Side effects and complications of laser therapy. DermatolClin 20:165-176, 2002

5. Trotter MJ, Tron VA, Hollingdale J, et al: Localized chrysiasis inducedby laser therapy. Arch Dermatol 131:1411-1414, 1995

6. Greve B, Raulin C: Professional errors caused by lasers and intensepulsed light technology in dermatology and aesthetic medicine: Pre-ventive strategies and case studies. Dermatol Surg 28:156-161, 2002

7. Alam M, et al: Clinically significant facial edema after extensive treat-ment with purpura-free pulsed-dye laser. Dermatol Surg 29:920-924,2003

8. Dinehart SM, Flock S, Waner M: Beam profile of the flashlamp pumpedpulsed dye laser: Support for overlap of exposure spots. Lasers SurgMed 15:277-280, 1994

9. Nanni CA, Alster TS: A practical review of laser-assisted hair removalusing the Q-switched Nd:YAG, long-pulsed ruby, and long-pulsed al-exandrite lasers. Dermatol Surg 24:1399-2405; discussion 1405, 1998

0. Willey A, et al: Complications of laser dermatologic surgery. LasersSurg Med 38:1-15, 2006

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