ALLISON T. VIDIMOS, RPH, MD CHAIRMAN, DEPARTMENT OF

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CUTANEOUS LASER SURGERY

• ALLISON T. VIDIMOS, RPH, MD
• CHAIRMAN, DEPARTMENT OF DERMATOLOGY
• CLEVELAND CLINIC FOUNDATION

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CHARACTERISTICS OF LASER LIGHT

• COHERENCE energy waves are in phase both
  spatially and temporally
• COLLIMATION - laser light waves are parallel
  and are propagated over long distances without
  divergence
• MONOCHROMATIC laser light is a discrete
  wavelength and color, which is determined by the
  laser medium
• INTENSITY laser light is delivered in very high
  powers

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CCF DEPARTMENT OF DERMATOLOGY LASERS

• VASCULAR
• VBeam 595nm
• NONABLATIVE RESURFACING
• Smoothbeam 1450nm
• Affirm 1440/1320nm/IPL
• ABLATIVE RESURFACING
• Ultrapulse CO2 10600nm
• Ultrafine erbium 2940nm
• Fraxel CO2 10600nm

• PIGMENTED LESIONS/TATTOO REMOVAL
• QS 532nm
• QS 755nm
• QS 1064nm
• HAIR REMOVAL
• LP 755nm
• LP 1064nm
• EXCIMER 308nm

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LASER RESURFACING

• Ablative
• Carbon Dioxide
• Erbium
• CO2/erbium
• Fractionated CO2, erbium
• Nonablative
• FLDL 585nm, 595nm
• Diode 980nm
• Nd YAG 1064nm, 1320nm
• Diode 1450nm
• Erbium glass 1540nm
• Intense pulsed light
• ALA PDT
• Fractional lasers

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CO2 ERBIUM LASERS
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ERBIUM CO2 LASERSINDICATIONS

• ERBIUM LASER (short pulsed)
• - Mild rhytids in non-movement areas
• - Mild atrophic acne scars
• - Diffuse blotchiness
• - Epidermal lesions (LEN, warts, keratoses,
  etc)
• - Nonfacial resurfacing
• CO2 LASER
• -Periorbital , perioral or forehead lines,
  mild
• dermatochalasis, cautious nonfacial
  resurfacing
• - Moderate to severe atrophic acne scars
• - Epidermal lesions (keratoses, warts)
• - Rhinophyma, angiofibromas, sebaceous
  hyperplasia
• - Other - Hailey - Hailey dx, Dariers dx,
  psoriasis

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NONABLATIVE LASER SKIN RESURFACING

• Subsurfacing
• Heats water in dermis -gt new collagen production
• May require multiple Rxs
• May not address roughness and dyschromias
  (intense pulsed light has improved these
  parameters)
• Results frequently subtle

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NONABLATIVE SKIN REJUVENATION

• ErbiumYAG in nonablative mode
• Plasma skin resurfacing
• Radiofrequency
• Combined radiofrequency/IPL
• Combined radiofrequency/910nm diode
• Fractional resurfacing 1540nm, 1440nm/1320
• Light emitting diode (LED)
• 1100-1800nm
• Radiofrequency/fractionated laser

• Diode 980nm
• Diode 1450nm
• NdYAG 1320nm with cryogen spray cooling
• Erbium glass 1540nm
• Flashlamp dye laser 585nm, 595nm
• Intense pulsed light
• ALA PDT

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FRACTIONAL LASER TREATMENT

• 1550nm SR750
• Fractional photothermolysis creates microscopic
  three dimensional patterns, depths of 300-800
  microns
• MicroThermal Zones (MTZs)
• Microscopic epidermal necrotic debris (MENDs)
  70-100 microns in diameter
• Re-epithelialization proceeds rapidly from viable
  epidermal stem cells and transient amplifying
  cell populations
• Series of Rxs, 5-7 days apart

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FRACTIONAL LASERS

• Fraxel (Reliant)
• SR750 1550nm
• SR1500 Restore 1550nm
• AFR Repair 10,600nm
• Lux (Palomar)
• Deep IR 850-1350nm
• 1540nm
• 2940nm erbium
• Affirm (Cynosure) 1440nm

• Pixel (Alma) 2940nm
• Active FX (Lumenis) CO2
• Scanlite (Iridex) visible light
• Profractional (Sciton) erbium
• Mosaic (Lutronic) erbium
• Slim Mixto SR 10,600nm

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Dermal Remodeling for Acne Vulgaris Smoothbeam
1450nm
Dynamic cooling 1450 nm laser
Thermal effect to epidermal protection
heats upper dermis Sebaceous
Gland
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LASERS AND LIGHT SOURCES FOR VASCULAR LESIONS

• Pulsed KTP 532nm
• Pulsed Dye 585nm
• Long Pulsed Dye 585, 590, 595 600nm
• Long Pulsed alexandrite 755nm
• Diodes 800, 810 930nm
• Long pulsed NdYAG 1064nm
• Intense Pulsed light 515-1200nm

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INTENSE PULSED LIGHT

• High intensity flashlamp emits a broad spectrum
  of noncoherent light from 500-1200nm
• Green, yellow, red, and infrared light
• Cut off filters used to select desired
  wavelengths
• Multiple pulse modes, fluences 3-90J/cm2
• Large rectangular footprint
• Minimal overlap

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INTENSE PULSED LIGHTCLINICAL APPLICATIONS

• Hair removal
• Rosacea
• Facial erythema
• Port wine stains
• Hemangiomas

• Ephelids
• Photorejuvenation
• Rhytids
• Scars
• Acne
• Tattoo

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VASCULAR LASERSINDICATIONS

• SUPERFICIAL HEMANGIOMAS
• Small
• Large
• TELANGIECTASIA
• Small, red
• Medium, red
• Violaceous
• PORT WINE STAIN
• Child
• Adult
• LEG TELANGIECTASIA
• Small red
• Large

• green, yellow
• infrared
• green, yellow
• green, yellow, infrared
• infrared
• yellow
• green, yellow, infrared
• Yellow (long pulse), infrared, green with cooling
• infrared

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Infantile HemangiomasDescription

• Rapid growth period 6 - 18 months
• Involution occurs in
• 50-65 of patients by age 5
• 70-80 by age 7
• 90-95 by age 9

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Infantile HemangiomasTreatment

• Active nonintervention
• Management of ulceration
• Systemic corticosteroid therapy
• Intralesional steroids
• Topical steroids
• Surgery
• Vascular lasers
• ? imiquimod
• ? propranolol

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FACIAL TELANGIECTASIAS

• Lasers are an excellent treatment for facial
  telangiectasias
• Longer pulse durations can be used at subpurpuric
  doses with little-no downtime
• An effective endpoint is vessel spasm, which may
  require multiple passes or pulse stacking
• Many larger caliber or deeper vessels require
  purpuric dosing or deeper penetrating lasers

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PORT WINE STAINS

• PWS is progressive vascular malformation that
  occurs in 0.03 of newborns
• Begin as pink patches which darken and thicken by
  adulthood
• Treatment should begin as early as possible
• Pulsed dye laser treatment is the gold standard
• Most patients require 6-12 or more rxs
• Approx 80 fading after 10 rxs
• Less favorable response sites V2, distal
  extremities

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PWS LASER PEARLS

• Purple is good, gray is bad
• Apply topical ointment to crusted areas
• Treat outline of PWS first
• Darker skin types require longer wait times
  between rxs (8-16 weeks)
• Begin treatments with largest available spot size
• Target vessels can be increased by heat
  application or dependent position
• 755nm laser for recalcitrant PWS

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LEG TELANGIECTASIAS

• Sclerotherapy remains the gold standard
• Treat the deep incompetent feeder vessels first
• Consider vessel size, depth and patient skin type
  in selecting appropriate laser
• Indications for laser
• Needle phobic patients
• Contraindications to sclerotherapy
• Small vessels
• Telangiectatic mats after sclerotherapy

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PIGMENTED LESION LASERS

• Yellow and green light lasers
• Pulsed systems Flashlamp pumped pulsed dye
  (585-600NM)
• Frequency
  doubled QS NdYAG (532nm)
• Non pulsed Copper vapor (511nm)
• Krypton
  (520-530nm)
• Red light lasers
• Q - switched ruby (694nm)
• Q - switched alexandrite (755nm)
• Infrared and Near infrared lasers
• Diode 800-810nm Q-switched NdYAG (1064nm)
• Intense pulsed light

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PIGMENTED LESION LASERSIndications

• EPIDERMAL
• Café au lait macules
• Ephelides, lentigines
• Vitiligo
• Melasma (epidermal)
• Beckers nevus
• Nevus spilus

• DERMAL
• Nevus of Ota and Ito
• Post-inflammatory hyperpigmentation
• Drug induced pigmentation
• Postsclerotherapy pigmentation
• Ochronosis
• OTHER - nevi (controversial)

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PIGMENTED SKIN LESIONSTREATMENT PEARLS

• Recognize depth of pigment to determine best
  laser options
• Woods lamp evaluation can help determine depth
  of pigment, with more superficial pigment
  accentuation
• Longer wavelengths are needed to treat dermal
  pigmentation
• Avoid pulse stacking or overtreatment due to risk
  of PIH

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PIGMENTED SKIN LESIONSTREATMENT PEARLS

• Transient epidermal whitening after laser
  irradiation is a useful clinical endpoint
• Clear membrane (e.g. Vigilon or Second Skin)
  placed over treatment site minimizes risk of
  blood or tissue splatter with QS lasers, but
  requires slightly higher fluence

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CAFÉ AU LAIT MACULES

• Occur in up to 20 of population
• Light to dark brown uniformly pigmented patches
• Success of laser treatment is highly variable
  with high recurrence rates up to 50
• QS 532nm, QS ruby 694nm, QS alexandrite 755nm are
  used erbium 2940nm may be used
• Avoid sun exposure to minimize risk of
  repigmentation of CALM
• Multiple treatments at 6-8 week intervals
• CALM that remain clear at one year usually have
  sustained results

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NEVUS OF OTA

• Blue-gray hyperpigmented patch in the periorbital
  lesion, may involve sclera
• Cervical or thoracic location Nevus of Ito
• Dermal depth of pigment requires longer
  wavelengths for effective treatment
• QS NdYAG, QS ruby, QS alexandrite
• Lightening may take months
• Treatment in children may result in complete
  clearance with fewer sessions

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TATTOO REMOVAL

• Acids
• Salicylic, TCA, phenol, sulfuric, tannic, zinc
  chloride
• Gentian violet
• Dermabrasion
• Salabrasion
• Cryosurgery
• Infrared coagulation
• Excision (single or staged)
• Lasers
• Selective
• Nonselective

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TATTOOSCOMPLICATIONS

• Pyogenic infections
• Non-pyogenic infections
• Hepatitis, leprosy, syphilis, tuberculosis,
  molluscum
• Cutaneous diseases flare or localization
• Psoriasis, lichen planus, Dariers, verrucae,
  KAs, discoid LE
• Miscellaneous
• Keloid scars, sarcoid, granulomas,
  lymphadenopathy, skin cancer

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TATTOOSCOMPLICATIONS

• Allergy
• Delayed hypersensitivity
• Photoallergy (cadmium)
• Sometimes mixed with red or other colors
• Most common pigments
• Red (mercury)
• Yellow (cadmium)
• Green (chromium)
• Blue (cobalt)

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Tattoo Ink Colors and Choice of Wavelength
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TATTOO REMOVAL LASERSLimitations

• Inability to remove yellow ink
• Risk of hypopigmenation or depigmentation
• Incomplete removal of tattoo
• Requires 6-12 Rxs or more, with amateur tattoos
  requiring fewer than professional tattoos
• Studies have shown that picosecond pulses are
  more effective for tattoo removal, but these
  lasers are very expensive to build

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TATTOO REMOVAL LASERSide effects

• Permanent or prolonged hypopigmentation
• Irreversible ink darkening of cosmetic skin -
  color tattoos due to reduction of ferric oxide to
  ferrous oxide by laser light
• Sunblocks that contain metal oxides and salts s/a
  titanium dioxide may be flammable after exposure
  to high enery QS laser pulses
• Patients receiving parenteral gold may develop
  blue-gray discoloration after any short pulsed Q
  - switched laser Rx
• Local allergic, granulomatous, or anaphylactoid
  reactions may occur

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HAIR REMOVAL METHODS

• Shaving
• Epilation
• - Plucking (Epilady, threading)
• - Electronic tweezers (Depilatron,
  Permatron,
• Removation)
• - Radiofrequency tweezers (Nutrolysis)
• - Waxing
• Depilatories
• Electrolysis
• Radiation
• Lasers
• Photodynamic therapy
• Vaniqa

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HAIR REMOVAL LASERS

• Selective photothermolysis, 600-1100nm
• Target is melanin in the bulb and bulge area of
  anagen hair, hair shaft and outer root sheath or
  topically applied chromophore (carbon particles,
  ALA)
• Initial lasers ideal laser pulse duration was
  between TRT for epidermis (3-10 msec) and TRT
  for hair follicle (40 -100 msec for HF 200-300um
  in diameter)
• Epidermal cooling

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HAIR ANATOMY
Epidermis Sebaceous Gland Bulge (1.5mm)
Follicle Vascular Supply (matrix)
Bulb (3-7mm)
Bulb / bulge are critical
structures responsible
for hair re-growth
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HAIR BIOLOGY
Catagen
Anagen
Telogen
-Follicles cycle through growth and dormancy
stages anagen growth ( 3 years, range 2-6
yrs) catagen - atrophy / loss of nourishment,
club hair (1-2 weeks) telogen - dormancy /
falls out (3-4 months) -Various anatomical
locations have different cycle durations -Follicle
s are in various stages of the cycle
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HAIR REMOVAL LASERS

• RUBY LASER 694nm
• DIODE LASER 800nm 810nm
• ALEXANDRITE LASER 755nm
• NEODYMIUMYAG LASER 1064nm
• PULSED LIGHT SOURCE with 590, 615, 645 690nm
  filters

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HAIR REMOVAL

• Laser efficacy
• - of hairs removed per session varies with
• system
• - Affects only anagen hairs
• - Approximately up to 20-30 reduction per
• treatment
• - Retreat at time of regrowth, which averages
  6-8 weeks

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HAIR REMOVAL LASERS
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LASER OR LIGHT SOURCE FOR HAIR REMOVAL
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Onychomycosislaser treatment

• LP 1064nm lasers approved for rx of onychomycosis
  2010 and 2011
• Laser heat kills tinea organsims, pseudomonas
• Treatment regimens not well defined
• Probably need to rx all 10 nails

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LASER HAZARDS

• Beam hazards
• Fire
• Oxygen
• Alcohol
• Methane
• Dry drapes/gauze/hair
• Hairspray/sunscreens
• Thermal burns
• Ocular damage
• Direct beam exposure or reflected light
• Tooth enamel injury

• Non-beam hazards
• Plume hazards
• Aerosolized tissue particles by Q-switched lasers

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KNOW THY LASER SAFETY MEASURES

• Post necessary signs stating laser in use, need
  for eye protection and potential dangers of
  exposure to laser light
• Use appropriate eye protection for patient,
  surgeon and staff members
• Fire proof the OR
• Wet drapes around surgical field
• Laryngeal mask airway (LMA) to avoid oxygen in
  laser field
• Remove reflecting surfaces (mirrors)
• Gloves and masks
• Smoke evacuator