Cutaneous Laser Cutaneous Laser Therapy (Surgery) Therapy (Surgery)

55thth year year

Lecture 2Lecture 2By Dr. Faraedon KaftanBy Dr. Faraedon KaftanConsultant DermatologistConsultant DermatologistCollege of MedicineCollege of MedicineUniversity of SulaimaniUniversity of Sulaimani

March. 27March. 27thth. 2011. 2011

* Light* Light has long played an has long played an important roleimportant rolein the treatment of skin diseases & in the treatment of skin diseases & introduction of lasers continues this introduction of lasers continues this important roleimportant role* * LasersLasers have an important & have an important & respected place in Dermatology respected place in Dermatology practice practice because because LasersLasers provide provide remarkably specific, precise, and remarkably specific, precise, and effective new forms of treatment for effective new forms of treatment for many disorders where no therapy many disorders where no therapy previously existed.previously existed.

LASERLASER is a device for the is a device for the

- creation, - creation, } } of a narrow, of a narrow,

- amplification & - amplification & }} intense intense

beam beam

- transmission - transmission }} of coherent of coherent lightlight

HISTORICAL ASPECTSHISTORICAL ASPECTS1. 1917 1. 1917 Einstein Einstein Quantum TheoryQuantum Theory

2. 1954 2. 1954 Towen Towen MASER (M:Microwave)MASER (M:Microwave) 3. 1957 Gordon Gould (coined the acronym 3. 1957 Gordon Gould (coined the acronym LASER) LASER) 4. 1960 4. 1960 Maiman Maiman Ruby-LaserRuby-Laser (1 (1ststLaser)Laser)5. 1961 5. 1961 JohnsonJohnson Nd-YAG LaserNd-YAG Laser6. 1962 6. 1962 Bennet Bennet Argon LaserArgon Laser7. 1964 7. 1964 Patel Patel CO2 LaserCO2 Laser8. 1980 8. 1980 Tunable-DyeTunable-Dye9. 1990 9. 1990 FPDLFPDL

The first page of The first page of Gordon Gould'sGordon Gould's

laser notebook, in which he coined laser notebook, in which he coined

the acronym LASER &the acronym LASER &

described the essential described the essential

elements for constructing elements for constructing

one.one.

* * Gordon Gould Gordon Gould made notesmade notes

about his ideas for a "laser" about his ideas for a "laser"

in 1957, which became an in 1957, which became an

important ingredient important ingredient of futureof future

lasers. The term "laser" was lasers. The term "laser" was

first introduced to the public first introduced to the public

PhysicsPhysics: Principal components:: Principal components:1. Active laser medium 2. Laser pumping 1. Active laser medium 2. Laser pumping energyenergy3. High reflector 4. 3. High reflector 4. Output coupler 5. Laser beam 5. Laser beam

Cross Section of a Common Cross Section of a Common Ruby LaserRuby Laser LaserLaser

Ruby LaserRuby Laser

Electromagnetic WavesElectromagnetic Waves: Light Light is a small is a small

segment of the electromagnetic spectrum that extends segment of the electromagnetic spectrum that extends from from radio waves to radio waves to -rays -rays * The * The only differenceonly difference among the different among the different waves is the waves is the

Wavelength (WL) & FrequencyWavelength (WL) & Frequency

WLWL

FrequencyFrequency

Electromagnetic Electromagnetic spectrumspectrum

γγ X rayX ray UVUV Visible Visible Infra redInfra red Microwaves Microwaves

Radio wavesRadio waves

Short waves Short waves Long wavesLong waves

λλwavelengthwavelength

( A( Aoo or nm )or nm )1nm =10A1nm =10Ao o 10000A10000Ao o == 1μm(0.001mm)1μm(0.001mm)

Light speed:Light speed: 300.000 Km/sec300.000 Km/sec

LASER LASER is an acronym foris an acronym for LLight ight AAmplification by mplification by SStimulated timulated EEmission of mission of

RRadiationadiationDifferences between Differences between

LaserLaser && Conventional light sourcesConventional light sources

Monochromatic: 1 WL Monochromatic: 1 WL Many wavelengthsMany wavelengths

Collimated: 1 direction Collimated: 1 direction Emitted in many Emitted in many directionsdirections

Coherent: Coherent: oscillatingoscillating Incoherent: Incoherent: Not oscillatingNot oscillating

(Vibrating(Vibrating) as a stable wave) as a stable wave as a stable waveas a stable wave

(aApparent visual angle

Properties of LaserProperties of Laser

1. Monochromic: 1. Monochromic: 1 WL1 WL

2. Collimation: 2. Collimation: 1 1

direction direction

3. Coherence: 3. Coherence: oscillating oscillating

as a stable wave as a stable wave

Lasers Lasers vs.vs. Conventional Light Conventional Light SourcesSources

(a

Apparent visual angle

laser sourcelaser sourceA collimated beam can be focused to aA collimated beam can be focused to asmall spot on the retinasmall spot on the retina

Conventional light sourceConventional light source

LasersLasers vs.vs. Conventional Conventional Light SourcesLight Sources

LED (Light Emitting Diode)

Nd:YAG Laser

Types of Laser:Types of Laser: Beams (WLs):Beams (WLs):1. Excimer Laser : 308 nm (126- 337 nm) 1. Excimer Laser : 308 nm (126- 337 nm) in Psoriasis & Vitiligoin Psoriasis & Vitiligo2. Argon Laser: 488 and 514 nm2. Argon Laser: 488 and 514 nm3. KTP Laser3. KTP Laser:(Potassium Titanyl Phosphat):(Potassium Titanyl Phosphat) 532 532 nm nm

4. PDL: 4. PDL: Pulsed Dye Laser:Pulsed Dye Laser: 577 nm 577 nm5. Ruby Laser: 694 nm beam5. Ruby Laser: 694 nm beam6. Alexandrite Laser: 755 nm6. Alexandrite Laser: 755 nm7. Diode Laser: 808-980 nm 7. Diode Laser: 808-980 nm 8. Nd:YAG Laser: 1064 nm= (532 X 2)8. Nd:YAG Laser: 1064 nm= (532 X 2)9. Ho:YAG Laser: 2100 nm 9. Ho:YAG Laser: 2100 nm 10. Erbium:YAG Laser: 2940 nm10. Erbium:YAG Laser: 2940 nm11. Co11. Co22 Laser: 10,600 nm Laser: 10,600 nm

ProtectivProtective e

Eyewear Eyewear GogglesGoggles

Widely-Used LasersWidely-Used LasersWavelength (WL) of OperationWavelength (WL) of Operation

1. Excimer Laser : 308 nm (126- 337 nm)2. Argon Laser: 488 and 514 nm3. KTP Laser: 532 nm (Potassium Titanyl Phosphat)4. PDL: Pulsed Dye Laser: 577nm5. Ruby Laser: 694 nm beam6. Alexandrite Laser: 755nm7. Diode Laser: 808-980nm 8. Nd:YAG Laser: 1064nm= (532 X 2) 9. Ho:YAG Laser: 2,100 nm 10. Erbium:YAG Laser: 2940 nm 11. Co2 Laser: 10,600 nm

Spectral output of several types of lasers.Spectral output of several types of lasers. Gas Gas laserslasers

CUTANEOUS LASER SURGERYCUTANEOUS LASER SURGERY and and Cosmetic DermatologyCosmetic Dermatology* * Almost no area of dermatology is changing as Almost no area of dermatology is changing as rapidly as that of cutaneous laser surgery.rapidly as that of cutaneous laser surgery.* Development of new laser, as well as * Development of new laser, as well as improvements improvements in existing laser, continues to advance the in existing laser, continues to advance the field. field. * Laser surgery has become an effective * Laser surgery has become an effective therapeutic therapeutic modality for a variety of dermatologic modality for a variety of dermatologic conditions.conditions.* * The first laser, a ruby laserThe first laser, a ruby laser, was operated , was operated in in 1960 by 1960 by Theodore MaimanTheodore Maiman. . * * Medical applicationsMedical applications were quickly were quickly recognized, & recognized, & Leon GoldmanLeon Goldman pioneered their dermatologic pioneered their dermatologic use use

* The * The WLWL is determined by the is determined by the active active mediummedium of of

each particular laser. each particular laser.

* * Active mediumActive medium can consist of: can consist of:

1. Gas (i.e. argon or CO1. Gas (i.e. argon or CO2 2 laser), laser),

2. Liquid (i.e. dye laser), or 2. Liquid (i.e. dye laser), or

3. A solid 3. A solid (ruby or yttrium-aluminum-garnet crystal (ruby or yttrium-aluminum-garnet crystal laser)laser)

* Light * Light can interact withcan interact with incident targets in1 of 3 incident targets in1 of 3 ways: ways:

11stst . Transmitted . Transmitted } } In the 1In the 1st st Transmitted & Transmitted & 22ndnd

}} Reflected the light Reflected the light

22ndnd . . ReflectedReflected }} has no effect has no effect

oror

33rdrd . . Absorbed:Absorbed: the light the light has effecthas effect

Light-Tissue Interactions:Light-Tissue Interactions: Tissue Tissue AbsorbersAbsorbersCutaneous TargetsCutaneous Targets (chromophores) that (chromophores) that

absorb the laser lights are:absorb the laser lights are:1. Melanin in Hair Epilation1. Melanin in Hair Epilation2. Hb in vascular lesions2. Hb in vascular lesions3. water in tumors3. water in tumors

* Medical procedures: only obtained by * Medical procedures: only obtained by absorptionabsorption of light of light

* Effects can be controlled by choosing * Effects can be controlled by choosing the the appropriate WL appropriate WL

* * When absorbed, the light energy is When absorbed, the light energy is transformed into transformed into →→ heatheat. .

* * Selective PhotothermolysisSelective Photothermolysis: : In In most cases of laser therapy, it is the most cases of laser therapy, it is the heatheat generated by absorption that generated by absorption that produces the desired effect. One produces the desired effect. One notable exception is photodynamic notable exception is photodynamic therapytherapy

Selective Photothermolysis:Selective Photothermolysis: was originally was originally promoted by Parish and Andersonpromoted by Parish and AndersonPhotothermolysis=Photothermolysis= heatheat production production →→ destruction of the destruction of the targettarget

* is the basis (concept) for all laser-tissue interactions:* is the basis (concept) for all laser-tissue interactions:1. The goal is to 1. The goal is to deliver a (WL)deliver a (WL) that is specifically that is specifically absorbed absorbed by the chromophoresby the chromophores (water, Hb, or melanin) (water, Hb, or melanin) inducinginducing → → heatheat build up and build up and →→ destruction of that targetdestruction of that target 2. In an ideal situation, the 2. In an ideal situation, the WL WL would have little or no would have little or no absorption absorption by by surrounding structuressurrounding structures. . 3.3. TRT: Thermal Relaxation Time TRT: Thermal Relaxation Time: is a property when : is a property when the the exposure timesexposure times and and energy delivered (fluence) energy delivered (fluence) are are controlled, the amount of heat build up can be controlled, the amount of heat build up can be confinructures confinructures to the desired target with minimal or no damage to surrounding to the desired target with minimal or no damage to surrounding structuresstructures4. Cooling is used to avoid damage to the surrounding structures4. Cooling is used to avoid damage to the surrounding structures

Lasers in Cutaneous surgery Lasers in Cutaneous surgery

are selected byare selected by matching of:matching of:

A. Lasers wavelength (WL)A. Lasers wavelength (WL)

withwith B. The absorption spectrum B. The absorption spectrum

of a desired skin targets: of a desired skin targets: (Melanin, HB or Water)(Melanin, HB or Water)

Continuous waveContinuous wave

PulsedPulsed

Repetitively pulsedRepetitively pulsed

* The laser is a technologically advanced * The laser is a technologically advanced

instrument. However, as with any instrument. However, as with any surgery, surgery,

side effects can occur: side effects can occur:

* * Side effects of laser:Side effects of laser:

1.1. Hypertrophic scarringHypertrophic scarring: the most : the most commoncommon

2. Pigmentary changes2. Pigmentary changes: the most : the most common common 3. Infection is possible3. Infection is possible

4. pain is possible4. pain is possible

5. lack of efficacy is possible 5. lack of efficacy is possible

Main indications in Laser therapies:Main indications in Laser therapies:

1. Hair removal in hirsute: 1. Hair removal in hirsute:

Hair Melanin is the targetHair Melanin is the target

2. Pigmentation, Melasma & Tattoo: 2. Pigmentation, Melasma & Tattoo:

Melanin is the target Melanin is the target

3. Vascular lesions: Hb is the target3. Vascular lesions: Hb is the target

4. Warts & Tumours: by Ablation 4. Warts & Tumours: by Ablation (cutting): (cutting):

Water is the targetWater is the target

5. Scars & wrinkles:5. Scars & wrinkles:

6. Excimer laser for: Psoriasis & Vitiligo6. Excimer laser for: Psoriasis & Vitiligo

MelasmaMelasma

TelangiectasiaTelangiectasia

Before Before After After

Laser TherapyLaser Therapy

wrinkleswrinkles

Before Before After After Laser Laser Rejuvenation:Rejuvenation:

Types of Lasers:Types of Lasers:1. 1. Both Both Lasers Argon & Cooper Lasers Argon & Cooper Vapor/Cooper Bromide Laser Vapor/Cooper Bromide Laser Have been Have been Replaced by other lasersReplaced by other lasers

2. Excimer lasers2. Excimer lasers

The first excimer laser was invented in The first excimer laser was invented in 1970

308 nm308 nm

Dermatological treatment is for:Dermatological treatment is for:

1. Psoriasis1. Psoriasis

2. Vitiligo2. Vitiligo

3. KTP (Potassium Titanyl Phosphat) 3. KTP (Potassium Titanyl Phosphat) LaserLaser * Produces a visible green beam of 532 nm. * Produces a visible green beam of 532 nm.

* For: Vascular, superficial pigmented & * For: Vascular, superficial pigmented & red red tattoostattoos

* The KTP laser is actually an Nd:YAG laser * The KTP laser is actually an Nd:YAG laser

which emits a WL of 1064 nm. which emits a WL of 1064 nm.

* The beam is passed through a crystal of KTP * The beam is passed through a crystal of KTP which which

reduces the WL by 50% producing the 532nm reduces the WL by 50% producing the 532nm WL. WL.

* can be Q-switched (quality switched), * can be Q-switched (quality switched), emitting a emitting a

beam in the range 0f 10 to 50 nsbeam in the range 0f 10 to 50 ns

4. Pulsed Dye Laser: 4. Pulsed Dye Laser: (PDL): (PDL): * was the first laser developed to specifically take * was the first laser developed to specifically take advantage advantage of the theory ofof the theory of selective photothermolyis selective photothermolyis * The laser medium is a rhodamine dye which * The laser medium is a rhodamine dye which initially was developed to deliver a initially was developed to deliver a wavelength of wavelength of 577nm577nm, coinciding with a specific Hb , coinciding with a specific Hb absorption absorption peak. (in the current generation of PDL the peak. (in the current generation of PDL the WL WL has evolved to be has evolved to be 595 nm595 nm))* Indications: * Indications: PDL PDL for the treatment of for the treatment of 1.1. Vascular lesionsVascular lesions: : The is extremely usefulThe is extremely useful

A. Port-wine stains, B. Telangiectasias, A. Port-wine stains, B. Telangiectasias, C. Erythemato-telangiectatic rosacea, C. Erythemato-telangiectatic rosacea, D. Hemangiomas. D. Hemangiomas. 2.2. WartsWarts: PDL has been effectively used : PDL has been effectively used

5. Ruby Laser (Q-Switched):5. Ruby Laser (Q-Switched): - Emits a red 694 nm beam- Emits a red 694 nm beam

- The 1st laser developed- The 1st laser developed

Indications of Ruby Laser :Indications of Ruby Laser :1. Tattoos with 1. Tattoos with black, , blueblue, and , and greengreen pigment. pigment. } } EffectivelyEffectively2. Macular pigmented 2. Macular pigmented lesions,lesions, such as lentigines, ephelidssuch as lentigines, ephelids} } treated treated & & nevus of Otanevus of Ota3. 3. café-au- lait maculescafé-au- lait macules, } respond, but, } respond, but4. Becker nevus, } the success4. Becker nevus, } the success5. Postinflammatory pigmentation } is unpredictable5. Postinflammatory pigmentation } is unpredictable6. Treatment of melasma is very disappointing, with some 6. Treatment of melasma is very disappointing, with some patients improving, some showing no response, and others patients improving, some showing no response, and others with temporary worsening.with temporary worsening.SEs of Ruby Laser :SEs of Ruby Laser :1. Crusting (immediate, takes approximately 7 to 10 days 1. Crusting (immediate, takes approximately 7 to 10 days to resolve. to resolve. 2. Both Hypo- and Hyper-pigmentation (Longer-term)2. Both Hypo- and Hyper-pigmentation (Longer-term)

6. Alexandrite Laser (Q-Switched) :6. Alexandrite Laser (Q-Switched) :

- uses the semiprecious stone (alexandrite) as the - uses the semiprecious stone (alexandrite) as the active mediumactive medium- The long WL (755nm) penetrates deeply into the - The long WL (755nm) penetrates deeply into the dermis with dermis with absorption by blue, black, and green tattoo absorption by blue, black, and green tattoo pigment. pigment. - shows a similar therapeutic profile to the Q-- shows a similar therapeutic profile to the Q-switched ruby laser switched ruby laser One advantage, however, is the ability to deliver One advantage, however, is the ability to deliver the alexandrite laser at 10 pulses/s, allowing for the alexandrite laser at 10 pulses/s, allowing for more rapid therapy compared with the single more rapid therapy compared with the single pulse/s delivery with the ruby laser. pulse/s delivery with the ruby laser. Disadvantages include a smaller beam diameter Disadvantages include a smaller beam diameter and less power.and less power.Lasers effectively treat tattoos are the : Lasers effectively treat tattoos are the : 1. Q-switched alexandrite laser 1. Q-switched alexandrite laser 2. Q-switched ruby and 2. Q-switched ruby and 3. Q-switched Nd:YAG lasers3. Q-switched Nd:YAG lasers

7. Neodymium:Yttrium-Aluminum-7. Neodymium:Yttrium-Aluminum-Garnet Laser (Nd: YAG) laserGarnet Laser (Nd: YAG) laser can be can be used in 3 modes: used in 3 modes:

a. Continuous wave }a. Continuous wave } These modes emit an These modes emit an invisibleinvisible

b. Q-switched }b. Q-switched } near-infrared beam near-infrared beam (1064nm) (1064nm)

c. Doubled frequency (KTP) c. Doubled frequency (KTP)

Because of the longer WL, the Nd: YAG Because of the longer WL, the Nd: YAG laser penetrates much deeper and laser penetrates much deeper and therefore is useful in treating more therefore is useful in treating more deeply seated or thicker lesions deeply seated or thicker lesions compared to shorter wavelength laserscompared to shorter wavelength lasers

Indications of (Nd: YAG) laser Indications of (Nd: YAG) laser 1. Black and Blue tattoo & Nevus of Ota : 1. Black and Blue tattoo & Nevus of Ota : Q-swiched mode is highly effective Q-swiched mode is highly effective 2. Red tattoo & superficially pigmented 2. Red tattoo & superficially pigmented lesions: lesions: (doubled frequency mode, the green 532 (doubled frequency mode, the green 532 nm beam)nm beam)3. hair removal in darkly pigmented patients: 3. hair removal in darkly pigmented patients: By extending the puls durationBy extending the puls duration4. vascular lesions, especially larger and 4. vascular lesions, especially larger and deeper vessels. Hemangiomas, vascular deeper vessels. Hemangiomas, vascular malformations such as port-wine stains, and malformations such as port-wine stains, and deeper larger caliber vessels: as Hb has a deeper larger caliber vessels: as Hb has a small peak at 1064 nm, the longer pulsed Ns: small peak at 1064 nm, the longer pulsed Ns: YAG laser has been usedYAG laser has been used

8. Erbium:Yttrium-Aluminum-Garnet 8. Erbium:Yttrium-Aluminum-Garnet Laser Laser

The Er:YAG laser emits an invisible near-The Er:YAG laser emits an invisible near-infared beam of 2940 nm, resulting in infared beam of 2940 nm, resulting in significantly more efficient absorption (16 significantly more efficient absorption (16 times) by water, and a more explosive times) by water, and a more explosive ablative effect, as compared to the CO2 ablative effect, as compared to the CO2 laser. As such, the Er:YAG laser results in laser. As such, the Er:YAG laser results in tissue ablation with less surrounding tissue ablation with less surrounding thermal damage.thermal damage.

In addition, this wavelength is close to In addition, this wavelength is close to a collagen absorption peak, thus a collagen absorption peak, thus allowing for collagen ablation much allowing for collagen ablation much more efficiently than the CO2. the more efficiently than the CO2. the decreased thermal injury and collagen decreased thermal injury and collagen ablation is an advantage for treatment ablation is an advantage for treatment of scars, photodamaged skin, and of scars, photodamaged skin, and rhytids (Fig.38-7). Some maintain that rhytids (Fig.38-7). Some maintain that healing may be slightly faster, with less healing may be slightly faster, with less risk of prolonged erythema and risk of prolonged erythema and scarring (especially below the jawline).scarring (especially below the jawline).

Nonetheless, depth of injury is the primary Nonetheless, depth of injury is the primary determinant for prolonged erythema and determinant for prolonged erythema and scarring. The decreased thermal damage can scarring. The decreased thermal damage can result in poor hemostasis with the Er:YAG result in poor hemostasis with the Er:YAG laser. To address this limitation, certain laser. To address this limitation, certain systems have a coagulation feature to limit systems have a coagulation feature to limit the amount of intraoperative bleeding. In the amount of intraoperative bleeding. In addition, the collagen-tightening effect may addition, the collagen-tightening effect may not be as pronounced as with the CO2 laser. not be as pronounced as with the CO2 laser. However, when similer clinical injuries and However, when similer clinical injuries and depth are achieved, studies have shown that depth are achieved, studies have shown that the Er:YAG and CO2 lasers have comparable the Er:YAG and CO2 lasers have comparable photorejuvinating effects, and similar photorejuvinating effects, and similar postoperative healing times and postoperative healing times and complication profiles. complication profiles.

9. Carbon Dioxide Lasers:9. Carbon Dioxide Lasers: COCO22 laser laser * Emits an invisible infrared beam of 10,600 * Emits an invisible infrared beam of 10,600 nm and can be used in continuous-wave or nm and can be used in continuous-wave or super-pulsed mode. super-pulsed mode. * Water nonselectively absorbs laser energy, * Water nonselectively absorbs laser energy, turning it instantly into steam, and producing turning it instantly into steam, and producing ablative and thermal damage. ablative and thermal damage. * Used in the superpulsed mode, the laser * Used in the superpulsed mode, the laser beam can be delivered in short bursts, beam can be delivered in short bursts, allowing thermal destruction of the epidermis allowing thermal destruction of the epidermis and papillary dermis while limiting deeper and papillary dermis while limiting deeper thermal damage. thermal damage. * Delivery in this mode is more uniform and * Delivery in this mode is more uniform and markedly faster when the optomechanical markedly faster when the optomechanical scanner is employed.scanner is employed.

Super-pulsed COSuper-pulsed CO22 lasers are extremely lasers are extremely useful in the treatment of useful in the treatment of

1. Actinic damage and 1. Actinic damage and

2. Photoaging2. Photoaging

The thermal injury causes conformat The thermal injury causes conformat changes within the collagen, leading to changes within the collagen, leading to clinical tightening. As such ablative clinical tightening. As such ablative laser resurfacing is extremely effective laser resurfacing is extremely effective at improving wrinkling, scarring, and at improving wrinkling, scarring, and skin tone.skin tone.

SEs include SEs include 1. postinflammatory pigmentary changes, 1. postinflammatory pigmentary changes, 2. scarring2. scarring3. textural changes 3. textural changes 4. prolonged erythema 4. prolonged erythema In addition, patients must be educated In addition, patients must be educated regarding the morbidity of the postoperative regarding the morbidity of the postoperative coursr and prolonged recovery associated coursr and prolonged recovery associated with ablative resurfacing. with ablative resurfacing. Used in the quasi continuous-wave mode, it Used in the quasi continuous-wave mode, it is an excellent therapeutic choice for very is an excellent therapeutic choice for very large planter and periungual warts, which large planter and periungual warts, which have failed to respond to routine office have failed to respond to routine office modalities.modalities.

Both a cutting mode and a defocused Both a cutting mode and a defocused ablative mode can be used with these ablative mode can be used with these systems to effectively excise the visible systems to effectively excise the visible verrucase and treat any residual human verrucase and treat any residual human papillomavirus in surrounding skin. Thr CO2 papillomavirus in surrounding skin. Thr CO2 laser is also an excellent treatment option for laser is also an excellent treatment option for ear lobe keloids but may not be as successful ear lobe keloids but may not be as successful for keloids elsewhere.for keloids elsewhere.

Other benign lesion amenable to CO2 laser Other benign lesion amenable to CO2 laser ablation include xanthelasma, rhinophyma, ablation include xanthelasma, rhinophyma, and syringgomas. Various malignant and and syringgomas. Various malignant and premalignant lesions also are effectively premalignant lesions also are effectively treated by laser ablation, including actinic treated by laser ablation, including actinic chelitis, and superficial basal and aquamous chelitis, and superficial basal and aquamous cell carcinomas cell carcinomas

Lasers for Hair EpilationLasers for Hair Epilation

1. Alexandrite1. Alexandrite

755nm755nm

2. Diode2. Diode

800nm800nm

3. Ruby3. Ruby

694nm694nm

4. Nd-YAG4. Nd-YAG

1064nm1064nm

Lasers for Vascular Lasers for Vascular

lesionslesions

1. Pulsed Dye1. Pulsed Dye

585nm585nm

2. Nd-YAG2. Nd-YAG

1064nm1064nm

3. Nd-YAG3. Nd-YAG

532nm532nm

4. Diode4. Diode

800nm800nm

Lasers for pigmented Lasers for pigmented

LesionsLesionsDermalDermal

1. Q-switched Ruby1. Q-switched Ruby

694nm694nm

2. Q-Switched Alexandrite2. Q-Switched Alexandrite

755nm 755nm

3. Nd-YAG3. Nd-YAG

1064nm1064nm

EpidermalEpidermal

1. Pulsed Dye1. Pulsed Dye

510nm510nm

2. Nd-YAG2. Nd-YAG

532nm532nm

Laser Hair RemovalLaser Hair Removal Laser hair removal is widely used for the Laser hair removal is widely used for the permanenet reduction of hair and this is one permanenet reduction of hair and this is one of the most popular laser procedures of the most popular laser procedures performed. performed. Most lasers for hair removal target the Most lasers for hair removal target the melanin within the folliclemelanin within the follicleWhite, blond, and grey hairs generally White, blond, and grey hairs generally respond poorly. respond poorly. As melanin is the target for these lasers, care As melanin is the target for these lasers, care must be taken in treating more darkly must be taken in treating more darkly pigmented patients to avoid epidermal pigmented patients to avoid epidermal damage. In this patient population, the damage. In this patient population, the longer pulsed Nd:YAG laser has allowed safe longer pulsed Nd:YAG laser has allowed safe treatment with fewer complications.treatment with fewer complications.

As hair is the target, patients must avoid As hair is the target, patients must avoid waxing, electrolysis, or plucking of hair prior waxing, electrolysis, or plucking of hair prior to laser hair removal. to laser hair removal.

Shaving prior to laser treatment is Shaving prior to laser treatment is acceptable (and is mandatory immediately acceptable (and is mandatory immediately prior to treatment to avoid epidermal injury) prior to treatment to avoid epidermal injury) and will not interfere with efficacy. and will not interfere with efficacy.

It appears that only hairs in the anagen It appears that only hairs in the anagen growth phase are permanently injured. growth phase are permanently injured. Therefore, sufficient time must elapse Therefore, sufficient time must elapse between treatments for hair to regrow and between treatments for hair to regrow and provide an appropriate chromophore for provide an appropriate chromophore for subsequent laser treatment, generally 8 to subsequent laser treatment, generally 8 to 12 weeks. 12 weeks.

Lasers used for hair removalLasers used for hair removalcan produce a significant reduction in can produce a significant reduction in both hair and papules/pustules in both hair and papules/pustules in patients with pseudofolliculitis barbaepatients with pseudofolliculitis barbae1. ruby (long pulsed) 1. ruby (long pulsed) 2. alexandrite (long pulsed) 2. alexandrite (long pulsed) 3. diode (long pulsed) 3. diode (long pulsed) 4. Nd:YAG lasers (long pulsed) 4. Nd:YAG lasers (long pulsed) 5. IPL. 5. IPL. Effective laser treatment of white and Effective laser treatment of white and blond hairs remains a challenge.blond hairs remains a challenge.

Ablative Laser ResurfacingAblative Laser Resurfacing

Both COBoth CO22 and erbium: YAG (Ei:YAG) and erbium: YAG (Ei:YAG) laserslasers are absorbed by water. Since are absorbed by water. Since water makes up 72% of the skin, they water makes up 72% of the skin, they effectively ablate the skin to varying effectively ablate the skin to varying depths depending on the energy depths depending on the energy delivered.delivered.

Indications: Indications:

1. Warts 1. Warts

2. Adnexal tumors2. Adnexal tumors

3. Skin cancers 3. Skin cancers

Early systems employed a continuous Early systems employed a continuous wave mode of emission, which lead to wave mode of emission, which lead to a greater degree of thermal damage a greater degree of thermal damage and risk of scarring. Newer high energy and risk of scarring. Newer high energy ultra-pulsed and computerized ultra-pulsed and computerized scanning systems have allowed a scanning systems have allowed a greater degree of control with laser greater degree of control with laser ablation, resulting in more predictable ablation, resulting in more predictable outcomes.outcomes.

Continuous waveContinuous wave

PulsedPulsed

Repetitively pulsedRepetitively pulsed

Laser Beam HazardsLaser Beam Hazards

Eye hazardEye hazard

Skin hazardSkin hazard

Laser Hazard ClassificationLaser Hazard Classification Accessible Emission Limit Accessible Emission Limit

(AEL)(AEL)laser systems are classified laser systems are classified on the basis of on the basis of

the : the :

1. Laser radiation1. Laser radiation accessible outside accessible outside the laser during the intended usethe laser during the intended use

2. Human eye or skin2. Human eye or skin is possible to be is possible to be exposed to the exposed to the laser radiationlaser radiation

Laser Hazard ClassificationLaser Hazard ClassificationClass 1 laser: Class 1 laser: Low powerLow power; ; Considered safeConsidered safe

Class 2 laser: Class 2 laser: Eye protectionEye protection afforded by the eye afforded by the eye blink responseblink response

Class 3 laser: Class 3 laser: Medium powerMedium power; ; Hazard to the eye Hazard to the eye from direct exposure from direct exposure

Class 4 laser: Class 4 laser: High powerHigh power; ; Hazard to the Hazard to the eye and skin from direct and reflected eye and skin from direct and reflected exposure; Fire hazardexposure; Fire hazard

Warning SignsWarning SignsExample: Class 2 LaserExample: Class 2 Laser

Warning SignsWarning SignsExample: Class 4 LaserExample: Class 4 Laser

Beam & Non-Beam HazardsBeam & Non-Beam Hazards

I. Beam Hazards: Skin HazardI. Beam Hazards: Skin Hazard Visible and infrared high-power lasersVisible and infrared high-power lasers

can cause can cause permanent skin damagepermanent skin damage or or damage to underlying organsdamage to underlying organs

Skin response to laser exposureSkin response to laser exposure are: are: 1. Mild to severe reddening1. Mild to severe reddening 2. Blisters and charring2. Blisters and charring 3. De-pigmentation3. De-pigmentation 4. Ulceration 4. Ulceration 5. Scarring5. Scarring

II. Non-Beam Hazards: II. Non-Beam Hazards: Fire:Fire: Ignition of materials can occur from Ignition of materials can occur from

direct or intense reflected or scattered direct or intense reflected or scattered beamsbeams

Electrical:Electrical: Most deaths caused by lasers Most deaths caused by lasers are caused by electrocution. Laser are caused by electrocution. Laser capacitors can retain high energy charges capacitors can retain high energy charges even when the power is offeven when the power is off

Laser-generated airborne Laser-generated airborne contaminants:contaminants:

Chemical fumes, aerosols of biological Chemical fumes, aerosols of biological contaminants including viable viruses contaminants including viable viruses and other biohazards can and do exist in and other biohazards can and do exist in the laser plume the laser plume

Chemical:Chemical: Laser dyes, solvents and Laser dyes, solvents and gases used may be toxic, explosive or gases used may be toxic, explosive or carcinogenscarcinogens

Maximum Permissible Exposure: Maximum Permissible Exposure: MPE: isMPE: is

Irradiance (Radiant Exposure) to which Irradiance (Radiant Exposure) to which a person can be exposed without a person can be exposed without

hazard to eye or skinhazard to eye or skin may cause discomfortmay cause discomfort depends on the following parameters:depends on the following parameters:

1. Laser wavelength1. Laser wavelength

2. Duration of exposure2. Duration of exposure

3. The MPE for eye exposure is 3. The MPE for eye exposure is much much

lower than the MPE for skinlower than the MPE for skin

Protective EyewearProtective EyewearThe protection wavelength(s) and The protection wavelength(s) and the corresponding attenuation are the corresponding attenuation are scribed on the eyewearscribed on the eyewearThe attenuation is given in Optical The attenuation is given in Optical Density (OD). An OD of 4 means that Density (OD). An OD of 4 means that the irradiance of the beam passing the irradiance of the beam passing through the eyewear is attenuated through the eyewear is attenuated by 10,000 times by 10,000 times

ProtectivProtective e

Eyewear Eyewear GogglesGoggles

Intense Pulse Light (IPL):Intense Pulse Light (IPL): * is quite different from a laser. * is quite different from a laser. * is a computer generated system, * is a computer generated system, which emits a broad spectrum of light which emits a broad spectrum of light WLs, photons from 500 to 1300 nm. WLs, photons from 500 to 1300 nm. * Special cut-off filters are used to * Special cut-off filters are used to block out WLs of light below the filter block out WLs of light below the filter number selected and allow only those number selected and allow only those WLs of light above the filter number to WLs of light above the filter number to pass through. pass through. * This makes the IPL system versatile. * This makes the IPL system versatile. Once a photon is absorbed by a Once a photon is absorbed by a chromophore, heat is released. chromophore, heat is released.

It is the release of heat by the photonIt is the release of heat by the photon, , around and within the microenvironment of around and within the microenvironment of the target chromophore, that must result in the target chromophore, that must result in biological damage to the target and biological damage to the target and hopefully its disappearance. hopefully its disappearance.

The released heat results in inflammation The released heat results in inflammation and injury to the pigmented lesion, resulting and injury to the pigmented lesion, resulting in slow elimination of the lentigine or in slow elimination of the lentigine or hyperpigmented lesion by the macrophages hyperpigmented lesion by the macrophages of our immune system.of our immune system.By incorporating the higher wavelengths By incorporating the higher wavelengths with this system you can now treat darker with this system you can now treat darker skin types and Class I and Class II wrinkles, skin types and Class I and Class II wrinkles, as well as treat leg veins. as well as treat leg veins.

When using the higher filters you will see When using the higher filters you will see improvement in the wrinkles, pore size and improvement in the wrinkles, pore size and skin texture. skin texture. The long wavelengths create a subclinical The long wavelengths create a subclinical dermal inflammation that stimulates the dermal inflammation that stimulates the conversion of a fibroblast into a fibrocyte. conversion of a fibroblast into a fibrocyte. Overtime, the activated fibrocyte then Overtime, the activated fibrocyte then produces new collagen. At the same time, produces new collagen. At the same time, existing collagen will shorten. existing collagen will shorten. The new collagen is organized into tight The new collagen is organized into tight fibrils. Accumulation of new dermal collagen fibrils. Accumulation of new dermal collagen over the course of several treatments results over the course of several treatments results in a thickening of the dermis and an in a thickening of the dermis and an apparent softening of the wrinkle, textural apparent softening of the wrinkle, textural irregularity or pore size. irregularity or pore size.

Intense Pulse Light (IPL):Intense Pulse Light (IPL):

There are many IPL machines that There are many IPL machines that preform very efficientlypreform very efficiently, however, in , however, in my opinion, the upgraded Vasculight my opinion, the upgraded Vasculight Plus (HR), is the most effective and Plus (HR), is the most effective and versatile device currently available versatile device currently available using the Intense Pulse Light using the Intense Pulse Light technology. technology. This is a proven and effective This is a proven and effective treatment that you can bring to your treatment that you can bring to your practice with confidence. It truly does practice with confidence. It truly does what it says it does.what it says it does. It works! It works! Patients Patients will see results and be happy. A happy will see results and be happy. A happy patient can generate on average four patient can generate on average four more patients. more patients.

Intense Pulsed Light: Intense Pulsed Light: (IPL) (IPL)

* is a device that uses a flashlamp * is a device that uses a flashlamp which emits a noncoherent broad which emits a noncoherent broad spectrum of light (from 400-1200 nm) spectrum of light (from 400-1200 nm) at various pulse durations and at various pulse durations and intervals. intervals.

* By employing filters to eliminate the * By employing filters to eliminate the lower wavelength, light from 560 nm lower wavelength, light from 560 nm and above can be used to treat various and above can be used to treat various cutaneous conditions. cutaneous conditions.

* has the advantage of treating more * has the advantage of treating more than one specific chromophore at a than one specific chromophore at a time.time.

IPL IPL has been used for the rejuvenation has been used for the rejuvenation of photoaged skin. Weiss et al of photoaged skin. Weiss et al demonstrated significant improvement demonstrated significant improvement in telangiectasias, pigment, and skin in telangiectasias, pigment, and skin texture of the face, neck, and chest texture of the face, neck, and chest with IPL. IPL has been combined with with IPL. IPL has been combined with topical aminolevulinic acid for topical aminolevulinic acid for photodynamic rejuvenation. By using photodynamic rejuvenation. By using IPL as the activating light source, IPL as the activating light source, patients benefit from the treatment of patients benefit from the treatment of actinic keratoses as part of actinic keratoses as part of photorejuvenation. IPL has also been photorejuvenation. IPL has also been effectively used for hair removal (see effectively used for hair removal (see below). below).

Intense Pulse Light (IPL):Intense Pulse Light (IPL):