Lasers in Dermatological Practice (PDF) (UnitedVRG)

LASERS
in Dermatological Practice
LASERS
in Dermatological Practice
Editors
Kabir Sardana MD DNB MNAMS

Professor
Department of Dermatology and STD
Maulana Azad Medical College
New Delhi, India
Vijay K Garg MD MNAMS

DirectorProfessor and Head
New Delhi, India
Forewords
Ganesh S Pai
B Krishna Rau
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Lasers in Dermatological Practice
First Edition: 2014
ISBN 978-93-5152-300-0
Printed at
Dedicated to
My colleagues, friends and foes, the last of which goad us to better ourselves
constantly
My wife Dr Supriya, who helps me to keep the balance between family and
academics
My daughter Zoya, who is the zing in my life
My parents, Mrs Amba Sardana and Major General Sardana who have
instilled discipline in my life
and
Lastly, the Department where over the years we have honed the skills in laser
intervention
Kabir Sardana
My family and friends

My wife Mrs Manju Garg, who has stood by me through times of strife
My son Devansh, who is pursuing his MBBS
and
My daughter Dr Ekta, who is a dentist
Vijay K Garg
Contributors
Anil Aggrawal MD Forensic Medicine (AIIMS)
Director-Professor
Forensic Medicine
New Delhi, India
Anil Ganjoo MBBS MD
Senior Consultant Dermatologist and
Head of Dermatology
Sunderlal Jain Hospital
Saroj Hospital and INMAS
New Delhi, India
Anjali Madan MD
Senior Resident
Department of Dermatology
and Lok Nayak Hospital
New Delhi, India
Anuj Tenani MBBS PGY-II
New Delhi, India
Anusha H Pai MD
Consultant Dermatologist
Derma-Care Skin and
Cosmetology Center
Mangalore, Karnataka, India
Atul M Kochhar MD DNB MNAMS FAAD
Senior SpecialistGrade I
New Delhi, India
Banwari Jangid MD
Department of Dermatology and
Venereology
All India Institute of Medical Sciences
New Delhi, India
Dharmendra Karn MD
Dermatologist
Dhulikhel Hospital
Kathmandu University
Teaching Hospital
Kavre, Nepal
Ganesh S Pai MD DVD
Senior Consultant Dermatologist
Derma-Care Skin and
Cosmetology Center
Inder Raj S Makin
MBBS (India) Dipl-Ing (Germany) RDMS PhD (USA)
Associate Professor
AT Still University
School of Osteopathic Medicine in
Arizona (SOMA)
Arizona School of Dentistry and
Oral Health (ASDOH)
Mesa, USA
Jaspriya Sandhu MBBS PGY-I
New Delhi, India
Kabir Sardana MD DNB MNAMS
Professor
New Delhi, India
Khushbu Goel MD
Pool Officer
New Delhi, India
viii Lasers in Dermatological Practice

Narendra Kamath MD DVD
Cutis Skin Care Center
Pavithra S Bhat MD
Kovai Medical Center and Hospital
Coimbatore, Tamil Nadu, India
Payal Chakravarty MD
Senior Resident
New Delhi, India
Rashmi Ranjan MD
Senior Resident
New Delhi, India
Rashmi Sarkar MD MNAMS
Professor
Maulana Azad Medical College and
LN Hospital
New Delhi, India
Chief Founder and Honorary Secretary
Pigmentary Disorders Society
New Delhi, India
Shahin S Nooreyezdan
MBBS MS MCh (Plastic Surgery)
PGIMER Chandigarh
Senior Consultant
Department of Plastic, Cosmetic and
Reconstructive Surgery
Indraprastha Apollo Hospitals
New Delhi, India
Shikha Bansal MD DNB MNAMS
Specialist
Safdarjung Hospital
New Delhi, India
Shivani Bansal MD
Senior Resident
New Delhi, India
Simal Soin
PG Dermatology (St Johns Institute of
Dermatology) London
MPhil Cambridge University UK
Medical Director and

Chief Cosmetic Dermatologist
Three Graces
New Delhi, India
Soni Nanda MD (Dermatology)
Shine and Smile Skin Clinic
Max Super Specialty Hospital
New Delhi, India
Sujay Khandpur MD DNB MNAMS
Professor
Department of Dermatology and
Venereology
All India Institute of Medical Sciences
New Delhi, India
Twinkle Daulaguphu MBBS PGY-I
New Delhi, India
Vanya Narayan MBBS PGY-III
New Delhi, India
Vijay K Garg MD MNAMS
Director-Professor and Head
New Delhi, India
Vivek Nair MBBS MD
Dr Nairs Skin Clinic (Palam Vihar)
Clinic Dermatech (Vasant Vihar
and Gurgaon)
Metro Hospital (Palam Vihar)
New Delhi, India
Foreword
Lasers have moved from the fringe of dermatology to a more
centrist path over the past decade. Fifteen years ago, when
lasers trickled into our country, they were considered to
be exotic and perhaps accessible to a select few. Cosmetic
dermatology and lasers have grown by leaps and bounds and
that necessitates that they are absorbed in the mainstream.
With close to half of the dermatologists now owning or having access to
lasers, it is important that our younger generation of dermatologists have
access to good practical textbooks as well as high quality equipment. This
book, Lasers in Dermatological Practice is best suited to educate our specialty
about the perils and pitfalls of using lasers.
Indian skin is unique since it comes commonly in 3 typesIV, V, VI.
Parameters will therefore vary depending on the skin types, a dilemma that
western books do not address. Postinflammatory hyperpigmentation will
vary in each skin type and even show variation among patients in a single skin
type. Such unpredictability and perplexing results are a cause of anxiety in a
cosmetologist at an inflexion point in his career. A comforting thought is that
our patients, except for a miniscule minority, are forgiving and compliant.
Most cases of tissue damage by laser will heal over time, nature coming to
our rescue. Our patience and reassurance will comfort patients in the interim
period.
In clinical dermatology, we have a chance to assess, judge and treat
patients. If there is an error of management, we can apply a midcourse
correction and modify therapy. Unfortunately, this is not true of lasers. A
mistake made, a poor assessment, using more or less power than required
can lead to laser burns and scarring. If it is on the face, as it is most of the
time, the consequences are not difficult to portend. Since there is no second
chance to repair damage, it is important to understand the basics of lasers
and the specifics of equipment much like reading a car manual before driving
your new car. This book does both and will hopefully lead to confident
cosmetologists and happy patients.
Ganesh S Pai MD DVD FAAD
Medical Director
Derma-Care Skin and Cosmetology Center, The Trade Center
Director-Professor, Department of Dermatology
KS Hegde Medical College, Deralakatte
Foreword
I thank the authors for giving me the opportunity to write the
Foreword to this excellent book, Lasers in Dermatological
Practice. The editors along with the co-authors have put
down their vast experience in the use of laser in various
dermatological conditions. It is a book of international
standards and, in particular, reference to the application
of lasers in brown and dark skin patients. Basics of laser in relation to skin
lesions are well-written.
The use of the different lasers in different dermatological lesions and the
step-by-step approach to each and every lesion is superb. The practical tips
to avoid wrong outcome is well-documented. The use of non-laser energy
sources in dermatological practice is very illuminating. The references at the
end of each chapter are apt and to the point.
The chapter on medicolegal aspects is pertinent and informative. On the
whole, it is the end result of the vast experience over the years that the editors
have acquired to write this book. I am confident that this book will find a
place in all dermatologists library.
B Krishna Rau
MS FRCS (Eng and Edin) FRCS (Thailand) (Hon) FIAMS FACG FICS FIGSC
Professor-Emeritus, Dr MGR Medical University

Honorary Fellow, American Surgical Association
President, World Federation of Society for Laser and Surgery Medicine
Chennai, Tamil Nadu, India
Preface
The genesis of this book arose from the common mechanistic approach where
we learn which buttons to push, in courses provided by the more reputable
device manufacturers just after a laser is purchased. This approach is foolish
beyond words, and can harm patients, and worse create medicolegal hazards.
There are some excellent books that we have referred to but most of them
deal with technologies that are nice to hear but too expensive to use in India.
Our book was initially planned as a companion to the hands on workshop
where the nitty gritty was left out while the topic in focus was discussed. Thus
the first edition was done with the help of Sun Pharmaceuticals. This edition
is the combined effort of Abbot and the vision of Shri Jitendar P Vij, who
convinced us to make it an elaborate yet compact book.
The book answers the three basic questions, what to do, why to do it and
how to do it? But our basic target is the dermatologists who need a step-bystep approach to the technology commonly used and not the laser that a
speaker in most conferences uses, which as a thumb rule is expensive, the
reason why the company sponsors the talk in the first place! Though the FDA
gives clearance of a device for a particular labeled indication, this cannot be
taken as any assurance that it will work safely and effectively enough to satisfy
the patients. Tragically, it may not be an understatement that a majority of
lasers bought in this country are not US FDA approved in the first place!
The book will also look at some questions that we rarely ask. What is the
histological depth of fractional lasers? Which type of atrophic scar actually
responds? Is Fr CO2 superior to Er:Glass? And many others.
As the field of cosmetic intervention usually encompasses indications
where novel non-laser technologies are used, we have covered radio
frequency, focused USG, plasma resurfacing and LED.
The book is planned in such a way where the commonly performed
procedures are discussed which gradually move on the advanced techniques.
Practical aspects like medicolegal hazards and pearls are discussed in
the latter half of the book. Some very useful information is provided in the
appendices.
Our contributors are largely those who are experts in their field of interest.
Our own work spanning over 8 years, with almost 5,000 procedures helped us
to bridge the gap between theory and practice.
But this is not a Cook Book and only a guide on the best approach is
provided. Individual laser parameters can vary, thus there is no substitute
for hands-on training, which cannot be obtained in this book or sitting in a
lecture hall more so when there are hundreds sitting in it!
Hope you like the effort. More will follow soon
Kabir Sardana
Vijay K Garg
Acknowledgments
We would like to thank our faculty residents and students of the department
some who have left to join other institutions, for their role in establishing and
developing the Laser Clinic at Maulana Azad Medical College (MAMC), New
Delhi, India.
Special thanks to Dr Vijay K Garg, Director-Professor and Head,
Department of Dermatology and STD, MAMC, who through his administra
tive acumen, managed to get the lasers. He has given me great support and
has served as a mentor throughout my professional career. His guidance and
encouragement over the years have influenced my efforts.
A special thanks to the team at M/s Jaypee Brothers Medical Publishers
(P) Ltd, New Delhi, India, especially Shri Jitendar P Vij (Group Chairman)
and Mr Ankit Vij (Managing Director), for latching on to the project, Mr PN
Venkatraman (Vice President-International), Mr Shashikumar Sambhoo, for
handling the publicity and sales and Mr Tarun Duneja (Director-Publishing),
Mr Subrata Adhikary (Commissioning Editor), Mr Lalit kumar (DTP Operator)
for helping with the deadlines.
A big thanks to our contributors, some of whom who have worked on their
chapter on a one month deadline! Each of them is an expert in their field.
Dr Simal Soin, Dr Shahin Nooreyezdan, Dr Inder Raj S Makin and Dr
Vivek Nair have worked on such a deadline. Dr Inder Raj S Makin has also
been kind enough to review two chapters for us and his comments have been
an asset to the chapters.
Dr Khandpur and Dr Anil Agarwal have also contributed after taking out
time from their busy schedule. Dr Atul M Kochhar who is also the Purchase
Officer at our Hospital has given nuances of buying lasers.
A big thanks to Dr Antje Katzer (Ascepelion), for letting us use the images
of the companys devices.
And lastly, our tributes to the countless patients who have taught us
dermatology and helped us to learn and relearn lasers!
xvi Lasers in Dermatological Practice
Real knowledge is to know the extent of ones ignorance

Confucius
Never sacrice your dignity to make money, but charge what you are
worth
Christopher B Zachary
Contents
Section 1: Conventional Laser Interventions

1. Basics of Laser-Tissue Interactions

2. Ablative Lasers
Overview 25
Ablative Laser Treatment of Common Conditions 52
Step by Step Approach 86
Atlas 93
3. Pigmented Lesions and Tattoos
Overview 101
Lasers For Tattoo Removal 115
Laser Treatment of Common Pigmented Conditions 131
Atlas 163
4. Fractional Photothermolysis
Overview 172
Laser Treatment of Common Conditions 204
Atlas 233
5. Vascular Lasers
6. Lasers for Hair Removal
3
25
101
172
236
252
Section 2: Advanced Laser Interventions

7. Nonablative and Subsurface Rejuvenation

8. Nonsurgical Tightening
9. Aesthetic Intense Focused Ultrasound (IFUS): Clinical Perspective
on Fitzpatrick Skin Types IIIVI
10. Noninvasive Body Contouring
11. Lasers for Scars, Keloids, and Stretch Marks
275
294
319
336
361
Section 3: Practical Aspects and Advances

12.
13.
14.
15.
16.
17.
18.
Miscellaneous Laser Responsive Disorders

How to Start a Laser Practice (Private Setup)
How to Set up a Laser Clinic in a Public Funded Institution
Therapeutic Pearls in Lasers
Medicolegal Aspects of Lasers in Dermatological Practice
Complications and their Management
New Aspects and Controversies in Lasers
379
416
421
432
441
455
471
xviii Lasers in Dermatological Practice
Appendices
Appendix 1:
Appendix 2:
Appendix 3:
Appendix 4:
Appendix 5:
Appendix 6:
Appendix 7:
Appendix 8:
Appendix 9:
Laser Safety/Eye Care

Consent Form
Procedure Checklist
Postoperative Care
Sample Operative Note
Sample Postoperative Instructions (Ablative Lasers)
Patient Information Sheet
Local Anesthetics
Select Bibliography
Laser and Medical Devices (Index)
493
504
506
507
512
513
514
528
538
541
Index543
Section
Conventional
Laser Interventions
Chapter
Basics of
Laser-Tissue Interactions
Kabir Sardana, Vijay K Garg, Shivani Bansal,
Jaspriya Sandhu, Twinkle Daulaguphu
Medical lasers have evolved over the years with numerous applications.
Dermatologic laser surgery is regarded as one of the fastest growing areas
in the emerging fields of photomedicine and biomedical optics. As with any
device, the most efficacious and appropriate use requires an understanding
of the basic photobiological and photophysical principles of laser-tissue
interaction as well as the properties of the laser itself. This chapter provides a
brief description of the nature of the laser, how it works, and the fundamental
mechanisms of its interaction with human skin.
Light
Light represents one portion of a much broader electromagnetic spectrum.
Light can be divided into the UV (200400 nm), VIS (400700 nm), NIR I
(755810 nm), NIR II (9401,064 nm), MIR (1.33 mm), and Far IR (3 mm
and beyond) (Fig. 1.1).
Normally, the percentage of incident light reflected from the skin surface
is determined by the index of refraction difference between the skin surface
(stratum corneum n = 1.55) and air (n = 1). About 47% of light is typically
reflected and is called the Fresnel reflectance because it follows Fresnels
equations relating reflectance to the angle of incidence, plane of polarization,
and refractive index. The angle between the light beam and the skin surface
determines the percentage of reflected light. More light is reflected at grazing
angles of incidence. It follows that, to minimize surface losses, in most laser
applications, one should deliver light approximately perpendicular to the
skin. One can deliberately angle the beam, on the other hand, to decrease
penetration depth and also attenuate the surface fluence by spreading the
beam.
On the other hand, the surface of dry skin reflects more light because
of multiple skin-air interfaces (hence the white appearance of a psoriasis
plaque). The light penetration into the epidermis depends on the wavelength dependent absorption and scattering. Because of scattering, much
incident light is remitted (remittance refers to the total light returned to the
4 Lasers in Dermatological Practice
Fig. 1.1: Absorption spectrum of various lasers in

relation to the major chromophores
environment due to multiple scattering in the epidermis and dermis, as well

as the regular reflection from the surface). In laser surgery, light reflected
from the surface is typically wasted. This lost energy varies from 15% to as
much as 70% depending on the wavelength and the skin type. For example,
for 1,064 nm, 60% of an incident laser beam may be remitted.
Tissue effects occur only when light is absorbed. The absorption
coefficient is defined as the probability per unit path length that a photon at a
particular wavelength will be absorbed and it depends on the concentration
of chromophores (absorbing molecules) present. The three primary skin
chromophores are water, hemoglobin and melanin (Fig. 1.1). Chromophores
exhibit characteristic bands of absorption at certain wavelengths. For
example, melanin absorbs broadly across the visible and ultraviolet (UV)
spectrum, the oxyhemoglobin and reduced hemoglobin in blood exhibit
strong bands in the UV, blue, green and yellow regions. Water has strong
absorption in the infrared (IR) region (Fig. 1.1).
Optical properties of the epidermis and dermis are different. In
pigmented epidermis, melanin absorption is usually the dominant process
over the majority of the optical spectrum (2001000 nm) (Fig. 1.1). In the
dermis, there is strong, wavelength-dependent scattering by collagen fibers,
which attenuates penetration of light. This scattering varies inversely with
wavelength. Thus as a thumb rule, between 280 nm and 1300 nm, the depth
Basics of Laser-Tissue Interactions 5
of penetration increases with wavelength. Above 1300 nm, penetration

decreases due to the absorption of light by water. The most deeply penetrating
wavelengths are 6501200 nm, while the least penetrating wavelengths are
within the far-UV and far-IR regions.
Types of Light Devices

Lasers contain four main components, the lasing medium, the excitation
source, feedback apparatus and an output coupler. The amplier of a laser
is the laser material that can be a solid, a gas, or a liquid. The feedback
mechanism is produced by the resonator, where the light is reected by two
mirrors so that the photons pass several times through the laser material. The
number of photons within the resonator increases exponentially due to the
stimulated emission (Fig 1.2).
With respect to lasing media, there are diode lasers, solid-state lasers, dye
and gas lasers.
Solid-state lasers include the Nd:YAG laser, Er:YAG laser, alexandrite
laser and the ruby laser. The gas lasers include the carbon dioxide (CO2)
laser, argon ion laser and the excimer lasers, while the diode and dye lasers
are singular in their class.
Light Device Terminology

Basic parameters for light sources are power, time and spot size for continuous
wave lasers and for pulsed sources, the energy per pulse, pulse duration, spot
size, fluence, repetition rate and the total number of pulses (Table 1.1).
At least for most ablative lasers, the effect of the laser beam on human
skin can be affected by any of three variables: power, time and spot size. The
effects of power and time are proportional whereas that of spot size (radius)
is an inverse square. If either the power or time is doubled, fluence increases
by a factor of 2. However, if the spot size is decreased by a factor of 2, fluence
increases by a factor of 4. Doubling the spotsize results in a four-fold reduction
in fluence.
Fig. 1.2: Various output modes of a conventional laser

Table 1.1 Various terminologies used in lasers
Power P (W)
For Cw lasers
Energy E = (J)
For Cw lasers
Power density W/A (irradiance)

(W/cm2) (A = effective area)
For Cw lasers
Peak power P max (W)
For pulsed lasers
Energy E per pulse (J)
For pulsed lasers
Pulse duration t [fs (10 )

to ms (103)]
For pulsed lasers
Energy density E/A (radiant

exposure) (J/cm2) (A = effective area)
For pulsed lasers
15
Cw: continuous wave, fs: femtosecond, ms: millisecond
Energy: Measured in Joules (J).

Fluence: The amount of energy delivered per unit area is the fluence,
sometimes called the dose or radiant exposure, given in J/cm2
Power: The rate of energy delivery is called power, measured in watts (W).
One watt is one joule per second (W = J/s).
Density: The power delivered per unit area is called the irradiance or power
density, usually given in W/cm2.
Pulse width :Laser exposure duration (called pulse width for pulsed lasers) is
the time over which energy is delivered.
Thus the lasers may be continuous, pulsed, quasi continuous and Q-switched
(Fig. 1.3).
The older lasers had pulse durations that varied from seconds to
milliseconds (0.01s/10-3). Millisecond CO2 lasers are gated lasers but largely
continuous wave in nature. The CO2 laser is a classic example of a continuous
mode laser. Microsecond lasers (0.000001 sec/10-6) are the ideal ultrapulse
lasers. Most Er:YAG lasers are also microsecond lasers. Another example is
that of the PDL where a single or a train of pulses is emitted.
Pseudocontinuous lasers (KTP) have very short pulses of light repeated at
very high repetition rates. Extremely short pulses are achieved by Q-switching.
These nanosecond lasers (0.000000001 s/109) are used in pigmented lesions
(Q-switched lasers). Recently picoseconds (0.000000000001 s/10-12) have
been used in tattoos.
Power density: It is a critical parameter, for it often determines the action
mechanism in cutaneous applications. For example, a very low irradiance
emission (typical range of 210 mW/cm2) does not heat tissue and is
associated with diagnostic applications, photochemical processes and
biostimulation. On the other extreme, a very short nanosecond (ns) pulse can
generate high peak power densities associated with shock waves and even
plasma formation.
Fig. 1.3: A figurative depiction of the energy and duration of

lasers based on the pulse width
Spot Size: Another factor is the laser exposure spot size (which greatly affects
the beam strength inside the skin).
Other important factors include aspects of the incident light (convergent,
divergent or diffuse) and the uniformity of irradiance over the exposure area
(spatial beam profile). The pulse profile, that is, the character of the pulse
shapes in time (instantaneous power versus time) also affects the tissue
response.
Operational modes: The Operational modes of lasers are Cw, pulsed as
interrupted radiation (in ms), pulsed free running (in hundreds of ms),
Q-switched (in ns) or mode-locked (in fs).
Continuous wave (Cw) laser may be differentiated from a pulsed laser,
which provides bursts of energy. In the Cw mode, the laser delivers a
continuous beam of light with little or no variation in power output over
time (Fig. 1.3). In Cw operation, laser output is controlled by the physician,
typically by depressing a foot pedal.
Interrupted radiation of a cw laser is done by mechanical or electronic
switching with modification of the pulse length. The pulse frequency is low
to moderate, up to 100 Hz. Flash lamp pumped solid-state lasers in the freerunning mode have pulse lengths of 50 ms up to several hundred micro
seconds. Pulses of medical dye lasers systems can vary from microseconds
to 50 ms. Superpulse is a term specific to some carbon dioxide lasers that
have been modified to produce very short pulses with high peak powers in a
repetitive fashion, commonly several hundred pulses per second.
Q-switching: Shorter pulses with very high intensities in the nanosecond
range are produced by Q-switching of the laser. The single, intense pulse with
a duration on the order of nanoseconds is produced. With Q-switching (the
Q-factor stands for quality factor, used in electronics theory terminology), a
fast electromagnetic switch (Pockel cell) in the laser cavity causes excitation
of the active medium to build-up far in excess of the level of the medium
when the shutter is open. In operation, the flashlamp is turned on and the
population inversion gradually grows. Lasing is prevented by the shutter.
When the population inversion is at a maximum, the shutter is opened so
that lasing occurs and a large burst of energy is emitted as the cavity rapidly
depletes the population inversion. The net result is an extremely high peak
power (greater than 106 W) nanosecond duration pulse or series of pulses.
Ultrashort laser pulses are generated by mode-coupling due to the
coherent properties of the laser. Compared to Q-switching, where the shortest
pulse durations are in the range of the resonator period, mode-coupling can
generate even shorter laser pulses.
Beam Profiles: Top Hat versus Gaussian

Laser beam profiles vary based on intercavity design, lasing medium and the
delivery system. A common profile is Gaussian or bell-shaped (Fig. 1.4). For
Fig. 1.4 : Comparison of the beam types of lasers. In most indications, the top hat
profile is preferred. The lower half of the figure demonstrates the conversion of a
Gaussian beam into a top hat beam, which can be achieved in certain laser
many lasers, this profile represents the fundamental optimized mode of

the laser. This shape is usually observed when the beam has been delivered
through an articulated arm. For some wavelengths, this is an effective way to
deliver energy (CO2 and Erbium). The disadvantage of the rigid arm is limited
flexibility, the typically short arm length, the possibility of misalignment from
even minor impact and a tendency for nonuniform heating across the spot.
The top hat beam ideally is better as there is uniform heating of the tissue.
Sometimes a bell-shaped profile is desirable, for example, when applying
a small spot FIR beam with a scanner. In this scenario, the wings of the beam
allow for some overlap without delivering too much energy at points of
overlap. The Gaussian profile can be modified outside the cavity, which is
desirable in many applications. With a fiber equipped delivery system, the
beam is mixed within the fiber and can be shaped to be more flat-topped.
Wavelength Ranges and Clinical Application

A useful way of understanding the effects and clinical application of
wavelength is to understand the interaction and depth of the different
wavelength in relation to the primary chromophores (Fig. 1.5).
1. UV laser and light sources have been used primarily for treatment of
inflammatory skin diseases and/or vitiligo, as well as striae. The XeCI
excimer laser emits at 308 nm, near the peak action spectrum for
psoriasis. The penetration is restricted to the epidermis (Fig. 1.5).
2. Violet IPL emissions, low power 410 nm LED and fluorescent lamps are
used either alone or with ALA.
Fig. 1.5: Optical penetration depth of common lasers used in dermatology
3. Green Yellow (GY): These wavelengths are highly absorbed by

hemoglobin (Hgb) and melanin and are especially useful in treating
epidermal pigmented lesions and superficial vessels (Figs. 1.1 and 1.5).
There are two issues concerning these lasers, one is their poor penetration
in skin (and the even poorer penetration in blood) which makes them
poor choices for treatment of deeper pigmented lesions or deeper larger
vessels. Similarly they are not useful for permanent hair reduction (with
the possible exception of very large spots (i.e., IPL) that enhance light
depth). The effective portions of many IPL spectra include the GY range.
By the proper manipulation of a laser delivery device, one can optimize
parameters for selective heating of pigmented versus vascular lesions.
Practical aspects of GY laser manipulation:

A. Applying a compression handpiece without cooling with 595 nm,
blood is depleted as a target and pigment is preferentially heated.

B. If the pulse duration is reduced to the nanosecond range,
melanosomes are preferentially heated over vessels. For example,
extremely short Q-switched 532 nm pulses will cause fine vessels to
rupture, but inadequate heat diffusion to the vessel wall precludes
long-term vessel destruction. On the other hand, melanosomes
are sufficiently heated for single-session lentigo destruction. By
choosing specific wavelengths with respect to hemoglobin and
melanin, one can achieve some degree of selective melanin or
hemoglobin heating.
4. Red and Near IR (I) (630, 694, 755, 810 nm): Deeply penetrating
red light (630 nm) continuous wave devices are efficient activators of
protoporphyrin after topical application of ALA. The 694 nm (ruby)
laser is optimized for pigment reduction and hair reduction in lighter
skin types. The 810 nm diode and 755 nm alexandrite laser, depending
on spot size, cooling, pulse duration and fluence can be configured
to optimize outcomes for hair reduction, lentigines or blood vessels.
They are positioned in the absorption spectrum for blood and melanin
between the GY wavelengths and 1,064 nm (Fig. 1.5). They will penetrate
deeply enough in blood to coagulate vessels up to 2 mm; also, they
are reasonably tolerant of epidermal pigment in hair reduction (with
surface cooling) as long as very dark skin is not treated. By decreasing
the pulse width into the nanosecond range, the alexandrite laser is a first
line treatment for many tattoo colors.
5. Near IR (II) 940 and Nd:YAG (1,064 nm): These two wavelengths
have been used for a broad range of vessel sizes on the leg and face.
They occupy a unique place in the absorption spectrum of the 3
chromophores, that is blood, melanin and water. Because of the depth
of penetration (on the order of mm), they are especially useful for hair
reduction and coagulation of deeper blood vessels. By varying fluence
and spot size, reticular ectatic veins, as well as those associated with
nodular port wine stains or hemangiomas, can be safely targeted. On the

other hand, they are not well-suited for epidermal pigmented lesions.
6. Mid infrared lasers and deeply penetrating halogen lamps: These
lasers and lamps heat tissue water. The absorption coefficients for the
1320, 1450, and 1540 nm systems are 3, 20 and 8 cm-1, respectively
and the corresponding penetration depths are 1500, 300 and 700 mm.
It follows that for equal surface cooling and equal fluences, the most
superficial heating will occur with the 1450 nm laser, followed by the
1540 and 1320 nm lasers. The MIR spectral subset has become the
mainstay for fractional non-ablative technologies.
7. Far infrared systems: The major lasers are the CO2, Erbium YAG and
Erbium:YSGG (chromium:yttrium-scandium-gallium-garnet) lasers.
Overall, the ratio of ablation to heating is much higher with the erbium
YAG laser.
However, one can enhance the thermal effects of the Er:YAG laser by
extending the pulse or increasing the repetition rate and likewise one can
decrease residual thermal damage (RTD) of the CO2 laser by decreasing pw
(pulse width). Details of the two lasers are given in the chapter on ablative
lasers.
Laser-tissue interactions
The actual laser interaction is characterized by a dissipation of energy though
an ideal situation is characterized by a direct straight line transfer of energy
(z) (Fig. 1.6). When photons strike the surface of the tissue, because of the
refractive index change, a portion (410%) of the photons are reflected
Fig. 1.6: Laser tissue interaction. Ideal laser penetration is a straight line (z) which is
not normally seen as the skin is not an optical window
according to the angle of incidence. Photons penetrating the surface initially

are refracted, obeying the law of Snellius, which states that photons entering
a medium with a higher refractive index are refracted towards the vertical axis
to the surface.
Of all the different interactions, the most important is absorption or
scattering.
Absorption
The coefficient a (cm-1) characterizes the absorption. The inverse, Ia,
defines the penetration depth (mean free path) into the absorbing medium
and is typically given as cm1. The absorption coefficient is chromophore
and wavelength-dependent. Absorbing molecular components of the
tissue are porphyrin, hemoglobin, melanin, flavin, retinol, nuclear acids,
deoxyribonucleic acid (DNA)/ribonucleic acid (RNA) and reduced
nicotinamide adenine dinucleotide. The absorption spectra of different
chromophores of biological tissue and water are plotted in Figure 1.1 while
the penetration is shown in Figure 1.5.
Chromophores
Blood, water and melanin are the main absorbing components in the tissue
(Fig. 1.1). Therefore, dye lasers and diode lasers effectively interact with blood,
the alexandrite laser with melanin and MIR lasers with the water content of
the tissue.
Hemoglobin: There is a large HgbO (oxyhemoglobin) peak at 415 nm,
followed by two smaller peaks at 540 and 577 nm. An even smaller peak is
at 940 nm. For deoxyhemoglobin (Hgb), the peaks are at 430 nm and 555
nm. The discrete peaks of hemoglobin absorption allow for selective vessel
heating. Although the 410 nm peak achieves the greatest theoretical vascular
to pigment damage ratio among the other peaks, scattering is too strong for
violet light to be a viable option for vascular applications.
Melanin: Most pigmented lesions result from excessive melanin in the
epidermis. By choosing almost any wavelength (< 800 nm), one can pre
ferentially heat epidermal melanin. Shorter wavelengths will create very high
superficial epidermal temperatures, whereas longer wavelengths tend to
bypass epidermal melanin (i.e. 1,064 nm).
Fat: Fat shows strong absorption at 1,200 and 1,700 nm. Although the ratios of
fat to water absorption are small, the small differences are exploited with the
proper choice of parameters.
1,200 nm might represent the best choice due to decreased overall water
absorption and therefore, increased penetration. Sebum is similar to fat but
also is comprised of wax esters and squalene.
Carbon: Carbon is a product of prolonged skin heating.
Once carbon is formed at the skin surface, the skin becomes opaque to
most laser wavelengths (that is, most energy will be absorbed very superficially.
It follows that the dynamics of surface heating changes immediately once
carbon is formed. This can be used creatively as an advantage. For example,
one can convert a deeply penetrating laser to one that would only affect the
surface by using a carbon dye. This has been accomplished with a laser peel
using a Q-switched Nd:YAG laser, though is is not commonly used now.
Collagen: Dry collagen has absorption peaks near 6 and 7 mm. With a free
electron laser operating at these wavelengths, collagen can be directly heated.
Scattering
The scattering behavior of biological tissue is important because it determines
the volume distribution of light intensity in the tissue. This is the primary step
for tissue interaction, which is followed by absorption and heat generation.
Scattering of a photon is accompanied by a change in the propagation
direction without loss of energy.
Scattering leads to an increase in the light intensity directly below the
tissue surface is enhanced by a factor of 24 as compared with the intensity of
the incident beam. The increased fluence rate is caused by scattered photons
overlapping with the incident photons. Another observation is that due to the
scattering effect, the penetration depth depends on the irradiated area.
Practical Implications
It has been shown that the light intensity directly below the tissue surface is
enhanced by a factor of 24 as compared with the intensity of the incident
beam. The increased uence rate is caused by scattered photons overlapping
with the incident photons. Because of the scattering effect, the penetration
depth depends on the irradiated area. Thus, the penetration depth will double
if for the same irradiance, the beam diameter increases from 1 mm to 5 mm.
Thus for treating port wine stains or for hair removal, 10 mm to 15 mm
spot diameters of the laser are recommended as it increases the depth of the
laser beam. In tattoos and nevus of Ota in case there is inadequate response ,
it is wise to increase the diameter of the probe to increase the depth.
Reaction Mechanisms
The rst systematic presentation of the reaction mechanisms of lasers with
tissue was by Boulnois and is depicted in the Figure 1.7. This highlights the
different tissue effects and thus smaller the pulse duration of the interaction
more the energy. Thus the Q-switched lasers like Nd:YAG can generate
photodisruptive fluencies due to the short time of impact.
The various tissue reactions include, Nonthermal reaction, chemical
reactions, thermal reactions (based on relaxation time), tissue ablation or
photodisruption.
Once the local subsurface energy density has been determined, heat
generation can be predicted by energy balance (conservation of energy), pulse
duration, thermal relaxation time and the wavelength specific absorption for
that target.
We will focus largely on the interactions relevant to commonly used
medical lasers.
1. Photothermal Reactions
Photothermal effects (1 ms100 s; 1106 W/cm2; Fig. 1.7)
The energy of the laser irradiation is transferred into heat due to the
absorption of the photons by tissue components, DNA/RNA, chromophores,
proteins, enzymes and water. According to the degree of heating, stepwise
and selective thermal damage can be achieved:
4245C: Beginning of hyperthermia, conformational changes and
shrinkage of collagen;
50C: Reduction of enzymatic activity;
60C: Denaturation of proteins, coagulation of the collagens, membrane
permeabilization;
100C: Tissue drying and formation of vacuoles;
>100C: Beginning of vaporization and tissue carbonization;
3001,000C: Thermoablation of tissue, photoablation and disruption.
Fig. 1.7: A figurative depiction of the plot of laser tissue interaction
Thermal diffusion is responsible for heat ow into the tissue. If the

exposure time with a laser pulse, tp, is short compared to the diffusion time,
td, then we have thermal connement and the pulse energy is converted
into heat.
Thermal diffusion and the extent of tissue necrosis are related. With low
laser power and long irradiation time, thermal necrosis is large. Shortening
the laser application time reduces the time for thermal diffusion and the zone
of necrosis becomes smaller. Minimum thermal necrosis is reached when the
irradiation time is equal to the thermal diffusion time or thermal relaxation
time. This is demonstrated by the laser interactions with pulsed CO2 lasers
(Fig. 1.8).
Thermal damage of the tissue is described by the Arrhenius rate equation
(Fig. 1.9). The consequence of this equation is that the threshold for tissue
damage depends on the laser power and the application time. This threshold
can be reached with high laser power in a very short time, resulting in a higher
temperature or with low power but long irradiation, where the threshold is
reached with lower temperature.
2. Tissue Ablation
The preconditions for tissue ablation are high absorption and very short
laser pulses. Analogous to the thermal confinement, one can define a stress
confinement when tissue is heated up so fast that the pulse duration is
Fig. 1.8: Example of the effect of pulse duration on tissue effect. (A) 3 J/cm2; 0.01 sec
(whitening); (B) 3 J/cm2; 0.40 sec (coagulation); (C) 9 J/cm2; 0.50 (cogulation with
ablation). Lower the irradiation time, lesser the coagulation the thermal necrosis
Fig 1.9: Time-temperature characteristic of tissue damage. Thus a 1s pulse reaches

the threshold at 65C, whereas a 10s pulse reaches the threshold at 57C
shorter than the propagation time. When the stress wave with velocity c
cannot leave the heated volume during the laser pulse, then it is removed
with the ablation of the material and the surrounding tissue is not damaged.
Only UV lasers (ArF excimer laser) and pulsed MIR lasers have such high
tissue absorption that they are effective ablating lasers.
Application: The threshold behavior of highly absorbed laser radiation,
e.g., the erbium-doped yttrium-aluminium-garnet (Er:YAG) laser with a
2,940 nm wavelength, can be used to modulate the thickness of necrosis in
soft tissue. Operation of the laser in normal ablation mode does not produce
effective thermal necrosis; therefore, no coagulation can stop bleeding. The
advantage is that the healing is fast with minimal scarring. However, for
precise superficial surgical interventions, it would be helpful if the Er:YAG
laser could be modulated to coagulate the tissue by a series of high-frequency
sub-threshold laser pulses. The energy of such pulses is below the ablation
threshold and therefore, is transferred into heat. The heat causes thermal
necrosis. The thickness of the necrotic tissue layer can be modulated by the
number of sub-threshold pulses.
3. Photodisruption
(10 ps100 ns:1081010 W/cm2)
Focused laser pulses in the nanosecond region (e.g. with a Q-switch
neodymium (Nd):YAG laser), or with a picosecond or femtosecond durations
(titanium (Ti) sapphire laser) develop power densities of 1012 W/cm and
more (Fig. 1.7). The electric field strength of this focused radiation is high
enough to pull electrons out of the atoms, forming a plasma and producing
an optical breakdown with shockwaves disrupting the tissue.
Application
A simple overview of laser tissue interactions as a function of time and depth
is given in Figure 1.8.
Lasers like Cw CO2 and Er:YAG classically have little thermal confinement.
Ultrapulse CO2 lasers, some Er:YAG lasers, long pulse Nd:YAG and alex
achieve thermal connement , wherein the pulse duration is shorter than the
thermal diffusion length or thermal relaxation time. The Q-switched lasers
and PDL achieve stress connement.
Effect of Cooling
Surface cooling enhances efficacy and safety in skin laser surgery, especially
for visible light technologies, (i.e., green-yellow light sources such as IPL, KTP
laser, and PDL) that are popular in cutaneous laser surgery. This is also the
wavelength range where epidermal damage is most likely. The epidermis is
an innocent bystander in cutaneous laser applications where the intended
targets, such as hair follicles or blood vessels, are located in the dermis.
Specifically, absorption of light by epidermal melanin causes skin surface
heating. The first goal is of surface cooling is preservation of the epidermis.
The second and related goal of surface cooling permits higher fluences to the
intended target (i.e., the hair bulb and/or bulge or a subsurface blood vessel).
Another benefit of surface cooling is analgesia, as almost all cooling strategies
will provide some pain relief.
4. Selective Photothermolysis (SPT)

Selective photothermolysis offered a mathematically rigorous rationale
for tissue-selective lasers. As described by Dr Anderson, extreme localized
heating relies on: (1) A wavelength that reaches and is preferentially absorbed
by the desired target structures; (2) An exposure duration less than or equal
to the time necessary for cooling of the target structures; and (3) sufficient
energy to damage the target. The heterogeneity of the skin allows for selective
injury in microscopic targets.
Thermal Relaxation Time and Pulse Duration

The thermal relaxation time (t) is the interval necessary for a target to cool to
a certain percentage of its peak temperature. Given that one goal of treatment
is the precise control of thermal energy, the pulse duration of laser irradiation
is just as important as optical and tissue factors. One way to maximize the
spatial confinement of heat is to use a laser with a pulse duration on the order
of the thermal relaxation time (TRT) of the target chromophore (Fig. 1.10).
TRT is defined as the time required for the heat generated by the absorbed
light energy within the target chromophore to cool to half of the original value
immediately after the laser pulse. During a lengthy laser exposure, most of
Fig. 1.10: Relation of pulse duration (p) and TRT (thermal relaxation time). p = TRT,
heat is confined to the vessel, p > TRT, there is dissipation energy outside the vessel
the heat produced diffuses away despite its origin in the target structure. The
target does not become appreciably warmer than its surroundings because
the absorbed energy is invested almost uniformly in heating of the tissue
during exposure. As a result, longer pulse durations offer a more generalized
heating and therefore, less spatial selectivity resulting in nonspecific thermal
damage to adjacent structures regardless of how carefully one has chosen
a wavelength (Fig. 1.10). However, if the laser pulse is suitably brief, its
energy is invested in the target chromophore before much heat is lost by
thermal diffusion out of the exposure field (Fig. 1.10). A transient maximum
temperature differential between the target and adjacent structures is then
achieved. Shorter pulse durations confine the laser energy to progressively
smaller targets with more spatial selectivity. The transition from specific to
nonspecific thermal damage occurs as the laser exposure equals and then
exceeds TRT.
When defining thermal relaxation time, the target size and geometry are
important (Box 1.1). For most targets, a simple rule can be used: The thermal
relaxation time in seconds is about equal to the square of the target dimension
in millimeters. Thus a 0.5 mm melanosome (5 10-4 mm) should cool in about
25 10-8 s, or 250 ns, whereas a 0.1 mm PWS vessel should cool in about 102s,
or 10 ms. This provides an approximate pulse width for varying degrees of
thermal confinement.
The often used term thermal relaxation time of the skin is meaningful
only when used for specific wavelengths (or specific skin structures, i.e., the
epidermis). With a ubiquitous absorber such as tissue water, it should be
considered within the context of the laser source. For example, if one uses

Box 1.1
TRT of potential targets used in dermatology
Melanosome (0.5 m)
0.25 s
Melanocyte (7m)
1 s
Nevus cell (10 m)
0.1 ms
Collection of nerves cells (100 m)
10 ms
Epidermis (100200 m) (dermoepidermal junction

10 m)
10 ms
Erythrocyte
2 s
Hair follicle (200 m )
40 ms
Vessel (0.1 mm diameter)
10 ms
300 ms
10 ms
Tattoo (0.5100 m)
20 ns3 ms
the 1,540 nm laser, the entire epidermis and large portions of the dermis
are heated and the TRT is on the order of seconds, because the thickness is
several hundred millimeters. So even though TRT of the epidermis is about
10 ms based on its thickness, a thicker slab of skin is heated at 1,540 nm, the
epidermis will take several seconds to cool because there is no temperature
gradient between it and that of the dermis. A summary of the TRT of major
target tissues is given in Box 1.1.
Application
With a very short pulsewidths (pw), lasers vaporize targets. For example, in
treating blood vessels, rapid heating results in acute vessel wall damage and
petechial hemorrhage (with Q-switched 532 nm). With intermediate length
pulses (0.11.5 ms), one can gently heat targets without immediate rupture
of the vessels. But intravascular thrombosis can create purpura and delayed
hemorrhage. With longer pulses (6100 ms), the ratio of contraction to
thrombosis increases and side effects are less likely. Too long pulses with very
small targets can create two problems. With highly absorbing targets, (i.e.,
tattoo inks), the heat generation is so great and long-lived that significant
diffusion occurs to the surrounding dermis. On the other hand, using a long
pulse YAG for a nevus of Ota results in an insufficient temperature rise as the
pigmented nevus cells cool off too fast during the delivery of the pulses (also
melanin absorption is much weaker than black ink).
Selective Photothermolysis of Tattoos

Amorphous carbon, graphite, India ink and organometallic dyes, typically
found in dark blue-black amateur and professional tattoos, have a broad
absorption in the visible and near-infrared portions of the spectrum. At visible
wavelengths longer than 600 nm, hemoglobin and melanin light absorption
is minimized and tattoo dyes can be targeted selectively.
The pigment granules characteristically found in tattoos have diameters
of 0.5100 mm, which correspond to TRT of 20 ns to 3 ms. With the
development of the Q-switched ruby (694 nm), alexandrite (755 nm), and
Nd:YAG (1.06mm) lasers, tattoo removal without scarring can be achieved.
The frequency-doubled, Q-switched Nd:YAG laser (KTP laser) emits at a
wavelength of 532 nm, which provides improved removal of red dye. Recently
picosecond lasers have been used for tattoos.
Selective Photothermolysis of Pigmented Lesions

Pigmented lesions can be divided in to epidermal and dermal. Although
highest in the ultraviolet portion of the spectrum, melanin absorption is also
significant in the visible and near-infrared wavelengths. The diameters of
individual melanosomes (0.51.0 m) and melanocytes (7 m) correspond
to TRT of 201,000 ns. Therefore, Q-switched green, red, and near-infrared
wavelengths have been utilized for this indication. Though Q-switched lasers
are used most commonly the gentle heating by the millisecond laser can also
treat epidermal disorders. With longer pulses (ms), the dermal melanocyte
does not become hot enough to achieve pigment reduction, thus ensuring
selective epidermal damage.
Selective Photothermolysis and Laser Assisted Hair Removal

The human hair follicle is a complex structure derived from both epidermal
and dermal components. The target chromophores, primarily melanin-rich
hair shafts, are located deep in human skin (bulge around 1.5 mm and bulb
at 27 mm). At this depth, only red and near-infrared wavelengths are useful
(690900 nm). The follicular structure responsible for regeneration has not
been conclusively identified and therefore, current systems target the entire
follicle. As a result, long pulse widths on the order of milliseconds and high
fluences capable of heating large volumes of tissue are required. Milliseconddomain ruby, alexandrite, diode and Nd:YAG lasers using high light doses
can produce selective injury to human hair follicles resulting in prolonged
growth delay and in some cases, permanent hair loss after a single treatment.
Selective Photothermolysis of Cutaneous Blood Vessels

The pulsed dye lasers at 577595 nm wavelengths well absorbed by the
targeted hemoglobin molecule relative to other optically absorbing structures,
cause selective thermal damage to dermal blood vessels while minimizing
epidermal melanin absorption. Furthermore, because the TRT for cutaneous
blood vessels varies between 10300 ms a variable pulse duration is required
for optimal results.
But there are numerous variations in pulse duration and absorption

of various chromophores (bloodless dermis, oxyhemoglobin and
deoxyhemoglobin) that can complicate this simplistic interpretation.
Practical Clinical Applications

There are numerous clinical applications that have been given in the text
above and the chapters that follow. Two examples are given below:
1. The geometry (and therefore the microscopic characteristics) of lesions
is important. For example, in the treatment for a nevus versus a lentigo,
the nevus is composed of melanocytes in aggregates as (collectively
of a size of 100 m in diameter) whereas the lentigo is a mere sheet of
melanocytes some 10 m thick. So the TRT of the nevus cell is about
10ms while that of the lentigo is about 0.1 ms (Box 1.1).
Thus, in treating nevus with a long pulsed alexandrite laser with a high
fluence, the TRT will approach a second. From the above equation, it
follows that thermal confinement will be high, and the peak temperature
will rise accordingly. More importantly, the thick slab of melanocytes
will take long to cool, such that there will be considerable heat diffusion
away from the target. On the other hand, the lentigo represents a slab
only tens of microns thick; there will be heat diffusion during the long
pulse and rapid cooling after the pulse. Thus, with ms-domain fluences,
the nevus case might result in scarring and a lighter lentigo might not
become hot enough for clearance. If one applies ns pulses to the two
lesion types, the lentigo shows a good response with possibly complete
clearing, whereas the nevus will require multiple sessions, as each laser
application will result in heat confined to the most superficial part of the
lesion. Conversely a microsecond laser might work for nevi.
2. Spot diameter: In general, the spot size should be 34 X > d (target
diameter), as larger spots make it more likely that photons will be
scattered back into the incident collimated beam. Photons scattered
out of the beam are essentially wasted. Larger beams (with the same
surface fluence as smaller beams) create deeper subsurface cylinders of
injury because there is less surface versus volume for photons to escape.
Basically, for small beams (narrow), scattered photons are carried out
of the beam path after only a few scattering events. Thus, as a thumb
rule, larger the spot, more the dermal/epidermal damage ratio but also
higher is the epidermal damage thus the fluence should be reduced.
For shallow penetrating lasers such as CO2 and erbium where the d <<
spotsize (all cases except for the fractional devices), the diameter of the
beam does not affect the tissue response. That is why equivalent results
can be obtained for skin resurfacing using pulsed CO lasers versus
scanned, tightly focused cw CO2 lasers.
How to use the Knowledge Practically?

The vast amount of data is of little meaning if used correctly. Thus in practice,
three principles have to be remembered on which laser applications are
applied.
1. Absorption spectra of various chromophores: It is important to
understand the wavelength that is absorbed by the target chromophore.
This is specially relevant in tattoos, thus accounting for the use of 532
nm (green) for a red tattoo and 1,064 nm (blue) for a black pigment. This
also accounts for the use of Er:YAG as an ablative tool for dermal tumors
where the target chromophore is water.
2. Pulse duration of the lasers: This is directly dependent on the size of
the target. This explains, why a Q-switched laser is used for a nanosized
tattoo and this also explains the logic of using a microsecond laser
(Er:YAG) is used for epidermal ablation (TRT 10 ms).
3. Penetration depth of laser: The optical penetration depth is a important
consideration specially in pigmented skin. As melanin has a wide range
of absorption spectrum, most lasers can be used, based on the above
two principles. The reason most of us use the Q-switched Nd:YAG is as
it penetrates deeper and thus would not interact with the competing
epidermal pigment, which is a competing factor in pigmented skin.
A summary of the indications and lasers used that largely conform to the
above principles is given Table 1.2.
Table 1.2 A summary of lasers used for common disorders

Vascular lesions
Pigmented lesions
Tattoo
removal
Photoepilation
Resurfacing
Ablation
PDL* (585600 nm)
QSRuby (694 nm)
QS Ruby
(694 nm)
Long-Pulse
Ruby (694 nm)
Carbon
dioxide *
(10,600 nm)
Long-pulse Nd:YAG
(1,064 nm)
QSNd:YAG *
(532, 1,064 nm)
QS Nd:YAG*
(532, 1,064
nm)
LongPulse
Nd:YAG *
(1,064 nm)
Er:YAG *
(2,490 nm)
Long-pulse KTP
(532 nm)
QS Alexandrite
(755 nm)
QS
Alexandrite *
(755 nm)
LongPulse
Alexandrite
(755 nm)
Fractional*
(1540 nm)
IPL
IPL
Long Pulse
Diode * (800
nm)
IPL*
* Used preferentially in pigmented skin

Not very effective
Exceptions
Inspite of these principles numerous laser applications are there which do not
always conform to these basic principles. This includes plasma resurfacing,
laser lipolysis, use of Q-switched lasers for melanocytic nevi and ablative
fractional lasers. In some, the target size have changed like for hair removal
lasers where the initial work focused on the bulge area but it now targets the
diameter and the hair shaft. In PWS, multiple issues arise including the size
of the vessels, the presence of deoxy or oxyHb and the depth of the vessels.
The pulse duration is being tweaked to adapt to the needs of the PDL. In
Tattoo cases, after the first few sessions, the optical property of the pigment
changes and macrophage engulfment changes the target size. The use of
the R20R technique for tattoos is a example where in all likelihood after the
first impulse the optical properties of the particle changes and the repetitive
impaction do not conform to the basic principles of laser tissue interaction.
One illustrative example is of the AFR (ablative fractional) lasers. The
approximate optical penetration depth (OD) in water for such lasers is
minimal, e.g., 1m for the Er:YAG laser (2,940 nm) and 10 m for the CO2
laser (10,600 nm). But they are used for acne scars which can involve the
lower dermis. This is as high volumetric energy densities are reached virtually
instantaneously within the focus of the laser beam, and therefore such lasers
can quickly advance a cavity deep into the tissue during the pulse. Due to this
process, it is possible that the resulting depth of an MTZ can greatly exceed
the optical penetration depth of any particular laser wavelength. Also the
optical penetration depths provided are approximations of the penetration
depth in water which can vary substantially and is approximately 30% for the
epidermis and 70% for the dermis. As the optical properties of water are also
temperature, dependent, it has been reported that the rapid change of tissue
temperature during a laser pulse can dynamically alter the penetration depth
substantially.
Conclusion
There are numerous other interesting scenarios that can affect the laser
tissue interactions like optical clearing with hyperosmolar solutions, photon
recycling, using a polarizing lamp to enhance illumination and selective
cell targeting. But the basic principles that are used are an understanding of
the laser wavelength and chromophore interaction, the TRT and the pulse
duration.
Books
1. Nelson JS. An Introduction to Lasers and Laser-Tissue Interactions in
Dermatology. Principles and practices in cutaneous laser surgery. Editor: Arielle
NB Kauvar; Associate editor, George J Hruza; 2005.

2. Ross EV, Anderson RR. Laser Tissue Interactions. Cutaneous And Cosmetic laser
Surgery, Ist Edn. Mitchel P Goldman; 2006.
3. Ronald G. Wheeland Basic Laser Physics and Safety. In: Goldberg DJ (Ed). Laser
Dermatology. 2005.
4. Steiner R. Laser-Tissue Interactions. In: Raulin C, Karsai S (Eds). Laser and IPL
Technology in Dermatology and Aesthetic Medicine; 2011.
Bibliography
1. Boulnois JL. Photophysical processes in recent medical laser developments: a
review. Lasers Med Sci. 1986;1:47-66.
CHAPTER
Ablative Lasers
Kabir Sardana, Vanya Narayan, Rashmi Ranjan
OVERVIEW
Skin resurfacing is not a new concept; various methods have been used
extensively for almost a century. Dermabrasion, in its various forms, has been
used successfully for treating wrinkles and acne scars for several decades. It
has recently lost popularity due to the introduction of laser resurfacing, the
difficulty in obtaining precise depth control, and the release of blood-borne
viruses into the aerosol.
Chemical peeling, which still enjoys popularity, is largely a blind
procedure and is greatly dependent on multiple variables to obtain desirable
penetration depths. Although superficial (i.e., epidermal) peeling is very safe
and predictable, deeper chemical peels are less precise and can lead to either
inadequate or excessive penetration depth. Phenol and augmented phenol
peels can produce spectacular results in removing heavily sun-damaged
skin but are less suitable for darker and skinned patients, males and younger
patients.
Carbon dioxide laser resurfacing was favored as the preferred method
of skin resurfacing by many experts in aesthetic surgery. Although the short
and long-term improvement in sun damage and wrinkles can be extremely
dramatic, carbon dioxide laser resurfacing has significant morbidity, even
when performed by well-trained doctors. This includes redness, temporary
hyperpigmentation, permanent hypopigmentation and dermal pacification.
Though fractional lasers have largely replaced ablative laser resurfacing,
out interest is in using these lasers for common epidermal and dermal
disorders, where their role is paramount.
At present, three laser are used for ablative indications and as the
chromphore in all is water the difference lies in their relative affinity. As shown
in the Figure 2.1, the Er:YAG has a higher affinity than Er:YSSG with the CO2
having the least absorption for water. Thus the safest of all is the Er:YAG laser.
CARBON DIOXIDE LASERS

The continuous-wave carbon dioxide laser, producing infrared light with a
wavelength of 10,600 nm, was the first to be used for resurfacing procedures.
Fig. 2.1: Absorption spectrum of the three commonly used ablative lasers
Its wavelength is strongly absorbed by water, which is the most abundant

chromophore in the skin and comprises approximately 70 percent of its
total volume. This seemed to make it an ideal tool for generalized superficial
ablation. But its tissue-dwell time could not be precisely controlled and
far exceeded the 1 millisecond thermal relaxation time of the 20 to 30 m
of cutaneous tissue that absorbs CO2 light. Excessive thermal diffusion and
concomitant unintended tissue damage were the common results.
However, in the early 1990s, new pulsed and scanning CO2 lasers were
developed that could deliver very high peak fluences of at least 5 J/cm high
enough to vaporize cutaneous tissue in less than 12 milliseconds (Fig. 2.2).
The energy required for vaporization of the epidermis is 5 J/cm. For the
thickness of the tissue (2060 m), the TRT is about 800 s. This is achieved by
the ultrapulse lasers where a 250 mJ pulse using a 2.5 mm probe size achieves
much higher fluencies in a shorter time as compared to the continuous wave
(Cw) CO2. The superpulse laser is a mechanically shuttered laser whose
peak power is higher than Cw lasers but the average power over time is the
same. These pulsed systems can precisely and safely remove thin layers of
skin, between 20 m and 30 m with each pass, while leaving an acceptably
narrow zone of residual thermal damage: 25 m to 70 m, in contrast to the
200 m to 600 m zone produced by the continuous-wave CO2 laser.
Principles of Carbon dioxide Lasers

R Rox Anderson and Parrish coined the term selective photothermolysis
in 1983 to describe the process by which a chromophore is heated by laser
light absorption in a time period shorter than its thermal relaxation time.
The latter is the amount of time required for a material to lose 50% of its heat
by conduction to its surroundings. Thus, when a chromophore is heated by
selective photothermolysis, only the intended target is damaged and there
is minimal diffusion of heat and no consequent injury to the surrounding
Ablative Lasers 27
Fig. 2.2 : A comparison of the waveform of CO2 laser. Note that for the same energy
(X) generated by a ultraPulse (<1 ms) waveform, 5 superPulse waves are generated. A
continous wave is seven times longer than the ultraPulse for the same energy
structures. The mechanism of injury involves both thermal coagulation and/

or photoacoustic injury in the form of supersonic high pressure shock waves.
For both the CO2 and Er:YAG lasers, the predominant mechanism is
photothermal. The pulse fluence necessary to achieve vaporization and thus
ablation of skin tissue with the CO2 laser is 5 J/cm2 with a calculated TRT of
800 s. The unique aspect of CO2 laser is that for each 20 m that is ablated,
34 times this amount is damaged. It is this latter effect that allows for the
purported collagen remodeling and wound healing. This zone of coagulation
is modest compared to 1000 m layer of damage that results from Cw CO2
lasers.
Pulse Duration of Carbon Dioxide Lasers

Laser dwell time is the amount of time that the beam is on in one location.
Low power densities require longer dwell times to achieve the same effect as
high power densities. The longer the dwell time and the slower the heating, the
more desiccation and charring of tissue that results. Further heating of charred
tissue results in extremely high temperatures of 300600C. This is because
carbonized and desiccated tissue acts as a heat sink for laser absorption. There
is no buffer of water to absorb the heat and thus temperatures escalate rapidly.
The significance is that if a non-pulsed laser is used, a low pulse duration should
be used to minimize thermal injury.
Types of Lasers
Most clinicians use the superpulsed CO2 lasers, which deliver pulse energies
in the 1050 mJ range. The peak power per pulse is 210 times higher than Cw
CO2 lasers, but the average power over time is similar (Fig. 2.2).
The UltraPulse laser introduced by Coherent (now Lumenis) solved

the problem of having to create second (duty cycles pulses of pulses) with
the superpulsed lasers. This was the first laser capable of delivering very
high fluence pulses (200500 mJ) with large spot sizes capable of tissue
vaporization with a single pulse The depth of vaporization with an UltraPulse
laser was studied in pig skin using pulses of 250450 mJ. In human skin, the
depth of thermal damage using the ultrapulse laser was 20 m after one pass,
40 m after two passes, and 70 m after three passes.
Various modifications have been used with the CO2 laser. The Nova-Pulse
can generate 7 J/cm2 of fluence by rapidly moving a small spot size through
a computer pattern generator. The TruPulse (Tissue Technologies) laser
can produce peak powers up to 10,000 watts at very short pulse durations
(65125 s). Another laser system that can achieve results similar to those of
the UltraPulse is the Sharplan SilkLaser. This device offers two modes: the
FeatherTouch and SilkTouch. This scanned laser uses a continuous wave CO2
laser beam that is scanned over a defined pattern so rapidly that the tissue
dwell time in any given spot is less than 1 ms. Thus the effect is essentially the
same as that of a high-energy pulsed system.
How do the Different CO2 Lasers Compare?

Alster et al. compared four resurfacing lasers and found that they were
similar in histologic and clinical outcomes. Kauvar et al. studied the histology
of superpulsed, SilkTouch, and UltraPulse lasers in human skin and found
that after three passes, the SP and SilkTouch RTDs (residual thermal damage)
were both 150 m, the UltraPulse RTD was 70 m, and the Cw laser RTD
(10 W and 0.2 s exposure) was 400 m. Many investigators have compared
the various levels of RTD after three passes in LSR: a summary of which is
provided in the Table 2.1. The important aspect to note is the variation in the
thermal coagulation as shown in Table 2.2.
Can a Cw CO2 be Used Like an UltraPulse Laser?

As most laser practitioners rarely acquire a true ultraPulse laser, this is
a relevant practical point. It must be understood that the Silk laser and
UniPulse (Table 2.1) are essentially Cw lasers but achieve comparable RTD as
the UltraPulse. But the importance of setting cannot be overemphasized. This
is as a high dose or a high pulse duration can change the profile of the laser
completely. Putting simply a higher pulse duration can cause coagulation
upto 1000 m making it akin to a radiofrequency (RF) device. A comparison
is given below (Table 2.2) between the UltraPulse and Cw CO2. This shows
that if the optimal settings are used a Cw CO2 can behave like a UltraPulse
CO2 with little clinical difference.
A simple thumb rule is that energy levels from 79 J/cm2 with a pulse
duration of 0.3 ms (0.03 s) can safely replicate the results of most UltraPulse
Ablative Lasers 29
Table 2.1 Comparison of available CO2 lasers
Lasers
Typical settings
Typical safe
uence (J/cm2)
Typical RTD
after two to
three passes (m)
UltraPulse
Density 6, 300 mJ
7.5
90110
NovaPulse
Computer scanner
E16, 7 W
67
6080
Silk Laser
18 W/36 W
(with 200 mm
handpiece)
15/8
110/70
TruPulse
500 mJ
50
UniPulse
1618 W/20%
overlap
14
70
Table 2.2 Comparison of UltraPulse and Cw CO2

Lasers
UltraPulse
SilkTouch*
FeatherTouch**
Ist Pass
Epidermal vaporization
+20 m of dermal necrosis
Epidermal
vaporization
+70 m of dermal
necrosis
Epidermal
vaporization
+10 m of dermal
necrosis
2nd pass
Epidermal
vaporization
+100 m of dermal
necrosis
Epidermal
vaporization
+30 m of dermal
necrosis
3rd pass
Epidermal
vaporization
+50 m of dermal
necrosis
300 mJ, 2.25 mm spot, 100 W, density 6

*28 J/cm2, **10 J/cm2
CO2 lasers. And most importantly, with most CO2 lasers, there is no advantage
of exceeding 3 passes. A detailed explanation of the modes of Cw CO2 laser
in conventional dermatological indications will be discussed in the next
chapter.
What is the Comparison of UltraPulse CO2 with

Conventional Cosmetic Procedures?
A comparison between the ultrapulsed CO2 laser with various pulse energies
and numbers of pass and TCA peeling, dermabrasion, and Bakers phenol
peel on a porcine model showed that at typical pulse energies, one to three
passes produced a wound depth intermediate between a 35% TCA peel
and dermabrasion, but more superficial-than a phenol peel (Fig. 2.3). Thus
by varying the dose, epidermal or dermal depth can be achieved to target
Fig. 2.3: A comparison of the dose depth analysis of UltraPulse CO2 laser with
conventional modalities
the condition to be treated. This also highlights the fact that the CO2 laser, in
optimal settings, can match most conventional tools with better precision. A
point that is to be emphasized that the pulse duration of electrocautery and
RF is in seconds while the most rudimentary CO2 lasers have a maximum of
0.9 seconds. Thus, the thermal damage and consequent cosmesis of the CO2
is superior to any RF machine or electrocautery device.
Technique Tips
As most of the laser surgeons employ CO2 to treat dermal tumors we will
focus on this, though a similar principle can be applied to other indications.
For individual lesions, the growth is vaporized by using relatively low power
settings in the 3 W to 5 W range with a spot size that matches the size of the
lesion.
Importantly, as there is a concomitant thermal damage the entire lesion
may not be destroyed. Ablation should be carried to the level of the dermis.
As some residual thermal damage will extend 0.5 to 1 mm beyond the level of
ablation, this suffices in most cases and can be reliably achieved in 34 passes
(Table 2.3).
Ablative Lasers 31
Table 2.3 A comparison of salient aspects of CO2 (pulsed) and Er:YAG lasers
Parameters
CO2
Er:YAG
OD (Optical
penetration)
20 m
1 m
Ablation Threshold
TRT
5 J/cm2
800 s
0.51.5 J/cm2
1 s/Pulse duration 250 s
Ablation
Depth/pulse
2060 m*
Plateau at 4th pass
550 m
No Plateau
Range of thermal
Injury/pass
75150 m**
1550 m
Tissue Effects
Photothermal
Photomechanical
Tissue Levels
Epidermis = an opalescent aspect is

obtained
Papillary dermis = Pink color
Deep Papillary dermis = Chamois
leather appearance
Reticular dermis= Cotton thread
appearance due to collagen
Epidermis = Whitening
Papillary dermis = Pin point
bleeding
Reticular dermis = Uneven
surface (sebaceous glands)
brisk bleeding
Histological effect
Coagulation-crater around the

ablated area (necrosis, deep
thermal effect)
Precise and safe ablation

(limited thermal effect)
Safety of treatment
Necrosis makes control of ablation

depth difficult
High visibility of treatment

range, ablation depth can
easily be controlled
Depth of treatment
Treatment is not restricted to the

epidermis because of thermal
effect. Thus good for dermal
disorders
Superficial ablation of
epidermal lesions
Thermal effects
Collagen shrinkage because of

thermal effect
Less thermal damage
Wound healing
Prolonged wound healing due to

necrosis areas
Shorter healing time
Side effects
More
Less
*In human skin the depth of ablation peaks at 225250 m after 4 passes using 13 pulses, dose of
250500 mJ (ultraPulse)
**the coagulation varies from 20 m (1 pass) to 70 m at 34 pass, maximum 100 m
End Points
At the end of the day most surgeons do not use fixed settings but look for end
points to reliably ascertain when to stop the ablation procedure. Published
reports have correlated clinical signs with anatomic depths of ablation. A pink
color was found to correlate with superficial papillary dermis, a chamoiscloth appearance with papillary dermis and waterlogged cotton-thread
appearance for reticular dermis. This is true only for deep ablation such as
with treatment of plantar warts. When thinner layers of ablation are used,
as in resurfacing, these subtle clinical signs are not seen. Also it must be
understood that this also depends on the laser being used. If a UltraPulse
laser is used little residual thermal necrosis (less than 30 m) exists, thus
the thermal reaction will not be sufficient to coagulate fine papillary vessels,
and the tissue will be pink because of the visible capillary blood flow. This is
typical of the appearance of the tissue after a single laser pass removing the
epidermis. After a second or third laser pass, the laser reacting with the dermis
leaves almost 70100 m of thermal necrosis thus leading to hemostasis, thus
giving a whitish appearance. If further passes are given a yellowish brown
look will actually indicate thermal injury ! Thus it is advisable as far as CO2
lasers are concerned, that such signs should be abandoned and the laser
surgeon should aim at primarily ablating the dermatological indication,
restricting the dose and settings to a maximum of 34 passes.
A few simple rules to follow are:
1. Use a pulsed laser or ultrapulse laser at the lowest dosage and pulse
duration.
2. Aim for ablation of the tumor first or level it down to the surrounding
skin.
3. A low energy and pulse duration will ensure erythema of the papillary
dermis, which is a reliable end point.
4. Do not aim for a yellowish discoloration, as that sign in most non-pulsed
lasers is a reliable indicator of thermal necrosis!
ERBIUM:YAG LASER
Introduction
The Erbium:YAG laser, with its wavelength of 2940 nm, is absorbed by water
10 times more readily than the carbon dioxide laser (wavelength, 10,600 nm).
Consequently, it is absorbed more superficially within the skin, leading to
extremely precise ablation of the epidermis and dermis (Fig. 2.4).
The threshold fluence required for clean ablation is 1.5 J/cm, compared
with 45 J/cm2 for the carbon dioxide laser. The thermal relaxation time is 50
sec for the Erbium:YAG laser; the carbon dioxide TRT is 1 millisecond. The
thermal injury is markedly less for the erbium:YAG lasers.
The predictive depth (5 m/J), the less thermal damage, the progressive
depth achieved and faster healing it is preferred, specially for most
dermatological indications. Newer modified Er:YAG have been invented to
bridge the gap between the tissue effects with added coagulation (Box 2.1)
which is consequent to the variable pulse duration. The principle employed
is that if the pulse duration is less there is less coagulation while if the pulse
duration is increased the coagulation increases. This can lead to various
diverse settings (Fig. 2.5) and can closely approximate the CO2 laser.
Ablative Lasers 33
Fig. 2.4: Er:YAG ablation occurs after the threshold dose of about 1.8 J/cm2. The dose
and settings indicate both linear depth and coagulative effect of modified Er:YAG
system
Box 2.1
An overview of modulated Er:YAG lasers
Conventional Er:YAG
Short-pulsed
(250350 s)
1. Derma 20 (ESC Medical Systems

Haifa, Israel )
2. Continuum (Continuum
Biomedical Dublin, Calif )
3. Dermablate (Asclepion-Meditec
Inc, Jena, Germany)
Modulated Er:YAG
Variable pulse
(500 s10 ms)
Contour Sciton Laser Corp
Combined CO2 and Er:YAG

(50 ms/350 s)
Derma K ESC/Sharplan
Dual Mode* (350 s/

Thermal mode
Dermablate MCL 30
(Asclepion- Meditec Inc, Jena,
Germany )
(1s 20 Hz)
Variable Pulse
(1001000 s)
Dermablate MCL 31
* In the thermal mode, the frequency is firmly set to 20 Hz, which leads to rapid heating of tissue by
subablative pulses 2 (1 J/cm)
Fig. 2.5: Variable Pulse duration and the consequent tissue effect using
various modes (Er:YAG Dermablate 31)
Laser-Tissue Interaction
The short pulsed Er:YAG laser is a flashlamp-pumped yttrium-aluminumgarnet (YAG) crystal laser system doped with atoms of the element erbium.
Laser energy is generated within a cavity containing the flashlamp-excited
YAG crystal rod, mirrors at each end, and a cooling system. On exiting the
cavity, the laser light is focused into a beam delivery system that typically
incorporates an articulated arm which allows the use of hand pieces capable
of producing highly collimated beams. Erbium:YAG lasers used in cutaneous
resurfacing typically have a bell-shaped Gaussian laser beam profile. The
erbium:yttrium-aluminum-garnet (Er:YAG) laser produces light in the
near-infrared (IR) portion of the electromagnetic spectrum at 2.94 m. This
wavelength was discovered by Soviet researchers in 1975 and its clinical use
developed in Europe. The broad water-absorption band extends from just
under 2 m to beyond 10 m, ensuring superficial absorption of near-IR light.
The energy delivered by the Er:YAG laser with a pulse duration of 250 to
350 s is far below the 1 millisecond thermal relaxation time calculated for
that layer of human skin heated by the pulsed CO2 laser. However, because
of the short penetration depth the laser heated tissue is only 1 m thick
and this has a TRT of 1 m. Thus to minimize thermal damage the Er: YAG
laser emits approximately twenty 1 s micropulses in a macropulse burst of
approximately 200 s.
In contrast to the CO2 laser, the Er:YAG laser has 16 times greater affinity
for water and a significantly lower tissue ablation threshold (1.6 J/cm2) which
allows the Er:YAG to be operated at 8 to 10 times above its ablation threshold
in most resurfacing applications. Therefore, most of the energy delivered with
the Er:YAG laser is used to ablate and the residual thermal damage (RTD)
Ablative Lasers 35
is narrow. The Er: YAG laser causes vasodilation of dermal blood vessel and
causes transudation of fluid that maintains enough water to ensure efficient
ablation. The absence of coagulation results in bleeding as the vessels of the
superficial dermal plexus are severed.
The unique advantage of the laser is minimum thermal damage but
the disadvantage is minimum coagulation. Though modulated Er:YAG
lasers with increasing pulse duration are useful, another option is to give
subablative pulses (Fig. 2.4 ) which will achieve coagulation, but no ablation.
Most Er:YAG lasers have a ablation threshold 2 J/cm. At this fluence ablation
starts. Below 2 J/cm there is no ablation of tissue as the energy is not sufficient
to remove tissue, and it remains in the tissue and causes heat generation. In
thermal mode a low energy of 1 J/cm and a pulse repetition rate of 20 Hz
is used (Fig.2.4). Thus these multiple subablative pulses summate to cause
coagulation. These modifications can help close the gap between the Er:YAG
and CO2 lasers.
Technique Tips
The depth of ablation is a function of the pulse energy and spot size or
fluence. The singular advatage of Er:YAG is that depending on the pathology
of the lesion to be removed the dose can be set, as about 2 to 5 m of tissue
per J/cm2 is ablated per pass with currently available Er:YAG laser systems.
Thus, say if a syringoma with a depth of 300 m has to be targeted, a dose
of 10 J/cm2 can be used which can ablate the lesion in about 4 passes (10 J
4m = 40 m 5 passes = 200 m). As there is a concomitant thermal damage
of about 1550 m/pass, this dose can effectively remove the lesion.
End Point
The removal of the epidermis can be ascertained by the immediate erythema
of the papillary dermis. As there is little coagulation this is the simplest end
point to be ascertained. If it is a epidermal or dermal tumour ablation can
be achieved but with some concomitant papillary bleeding. But in case of a
scar or with dermal irregularities a tissue-sculpting mode is needed. This
is easily accomplished with a focused handpiece having a focal spot size of
1 to 2 mm. The ablation is done by holding the handpiece at an acute angle
to the tissue in a manner such that tissue elevations above the desired plane
are preferentially irradiated, thereby decreasing the risk of cutting holes or
troughs in the tissue. In case more passes are needed, brisk bleeding occurs
which is a reliable indicator of entering the lower dermis. A thermal mode or
varying the pulse duration effectively seals the vessels.
But the reliability of depth/energy means that the laser surgeon can
predict the depth in most cases by multiplying the energy in J/cm2 with a
factor of 5, with predictable depth abaltion.
Comparison (CO2 vs Er:YAG)

According to the theory of selective photothermolysis, three criteria must be
fulfilled to confine thermal damage to a selected target. First, the target tissue
must absorb a given wavelength more avidly than the surrounding tissue.
Second, the time the laser is in contact with the tissue (or pulse duration)
must be less than the thermal relaxation time, which is defined as the time
needed for a tissue to lose 50% of its heat. The pulse duration must be shorter
than the thermal relaxation time (approximately 200600 s for skin) to
minimize nonspecific lateral thermal damage, which can lead to scarring and
pigmentary change. Third, sufficiently high levels of energy must be delivered
to the target tissue to cause ablation.
The most crucial aspect is the thermal injury below the ablation zone
which is a double edged sword as, though it induce collagen remodeling
through heat-mediated contraction, but can cause damage if not controlled
properly. As seen in the Figure 2.6, the CO2 laser tends to reach the dermis
with the first pass as compared to the Er:YAG. Also beyond three passes there
is little added benefit as the coagulation and concomitant carbonization acts
as a heat sink causing more heat damage.
The erbium:yttrium-aluminum-garnet (Er:YAG) laser is characterized by
a thinner zone of ablation and thermal damage resulting in shorter healing
time and a lower rate of post procedure side effects compared with SP CO2
resurfacing lasers. The Er:YAG laser produces a different tissue reaction as
compared with the CO2 laser because of the greater absorption by the target
chromophore, water. Because the wavelength of the laser closely approximates
the absorption peak of water (3000 nm), nearly all of the energy is absorbed
in the epidermis and papillary dermis, yielding superficial ablation and less
underlying thermal damage compared with the CO2 laser. Vaporization of
water by the Er:YAG laser in the ablated epidermis and superficial dermis
allows cooling of the tissue as the heat escapes as steam and decreases the
heat transferred to the surrounding tissues. This allows the Er:YAG laser to be
used for several passes over the ablated area without greatly increasing the
zone of thermal damage (Fig. 2.6).
Each pass with the SP Er:YAG laser (250350 microseconds) ablates
approximately 20 to 25 m (at 5 J/cm). Depth of thermal damage has been
shown to be 30 to 50 m at fluencies of 5 to 8 J/cm2 compared with 50 to
200 m with the CO2 laser at fluencies of 3.5 to 6.5 J/cm. In addition, it
appears that even with the multiple passes of the Er:YAG laser, the depth
of underlying thermal damage is limited to 50 m. With multiple passes
at 5 J/cm2, it may approach that seen with the pulsed CO2 laser. No visible
contraction of dermal collagen fibers is observed with subepidermal passes
of the SuperPulse Er:YAG during resurfacing, however, collagen contraction
occurs at 55 C to 60 C and relies upon heating of the dermal tissue. Longerpulse (10 milliseconds) Er:YAG lasers have been shown to increase the zone
Ablative Lasers 37
Fig. 2.6: A comparison of the tissue effects of pulsed CO2 and Er:YAG lasers
(ablation, necrosis, coagulation, reversible thermal damage)
of underlying thermal damage to approximately 60 m, which may result in

greater skin tightening and wrinkle reduction but increased risk of secondary
side effects such as erythema and hyperand hypopigmentation.
A comparison of the effects of the two lasers systems is given in Figure 2.6
and Table 2.3 Due to the superior tissue dynamics and side effect profile the
variable pulsed Er:YAG is a superior laser system than CO2 lasers for most
dermatological indications except vascular and lympahtic tumors.
Combination of Er:YAG/CO2
For moderate to severe rhytides, a combination of CO2 and Er:YAG lasers is
often used to obtain better clinical results, while minimizing postlaser side
effects and complications. The procedure is started as mentioned earlier, with
attening of the rhytides or acne scar shoulders rst, followed by a single pass
over the rest of the cosmetic unit with the Er:YAG laser. The CO2 laser is then
used over the entire treatment area to induce collagen tightening. Often a
single pass with the CO2 is adequate, but on occasion, a second pass is needed.
After the CO2 laser, the Er:YAG laser is repeated in order to remove some of
the thermal damage produced by the CO2 laser. This sequence minimizes the
zone of thermal necrosis, and therefore shortens healing time and decreases
post-treatment erythema, while still inducing tissue contraction. Many laser
surgeons recommend performing two passes with the CO2 laser rst followed
by several passes with the Er:YAG laser. However, by using the Er:YAG laser at
the beginning, the epidermis may be ablated with minimal residual thermal
necrosis. This serves to eliminate one of the passes performed with the CO2
laser, which will also decrease the zone of thermal necrosis. Results attained
using this combined method approaches those attained with the CO2 laser
alone, and have a signicantly reduced healing time and a lower incidence
of complications.
An alternative to switching between two different lasers is to use an
Er:YAG laser with a variable pulse width (Contour from Sciton and CO3
from Cynosure). When used with a longer pulse duration, CO2-like effects
may be achieved. The increased pulse duration extends the zone of thermal
damage, induces collagen contraction, and coagulates small dermal blood
vessels. Shortening the pulse duration gives typical Er:YAG-like effects
with minimal thermal injury and supercial ablation. Therefore, the short
pulse mode can be used to initially smooth rhytides and scars, then the long
pulse mode can tighten tissue, and nally the short pulse mode used again
to remove the layer of necrotic tissue in order to hasten healing. Thus, one
can achieve results with one dual mode Er:YAG laser approaching those
only previously seen with the use of the CO2 laser. In addition, due to the
wavelength selectivity of the Er:YAG, the longer pulse delivers the CO2-like
benet of thermal damage and subsequent collagen contraction, whereas
decreasing risk of deleterious effects seen with the CO2 laser including
hypopigmentation.
ERBIUM:YSGG LASER RESURFACING

The Er:YSGG laser was approved by the United States FDA in 2008. It generates
a wavelength of 2,790 nm and has a water absorption coefcient that lies
between that of the Er:YAG (2,940 nm) and CO2 (10,600 nm) lasers (Fig. 2.1).
It was developed in an attempt to provide deeper dermal heating than the
traditional Er:YAG laser while still minimizing healing time. Like the Er:YAG
laser, the Er:YSGG laser removes a portion of the epidermis with a controlled
thermal effect. What makes it unique is that there is only minimal epidermal
tissue removal, thus creating a natural protective dressing that diminishes the
extent of the recovery process, similar to plasma skin regeneration technology.
It is primarily used for pigment, rhytides, and skin tone (Ross EV). A recent
study has used it for acne scars (Kim S), though it is the authors opinion that
it may not replace the current fractional lasers for this indication.
PLASMA SKIN REGENERATION

Plasma skin regeneration technology uses pulses of ionized nitrogen gas to
deliver heat energy directly to the skin. Like other ablative resurfacing lasers,
its development came from the desire to approach the results of traditional
Ablative Lasers 39
CO2 resurfacing without the lengthy recovery time. Unlike lasers, there is no
dependence on a specic target such as water, hemoglobin, or melanin.
The system uses energy from an ultrahigh-frequency radiofrequency
generator to convert nitrogen gas into plasma within the handpiece. The
plasma emerges from a nozzle on the handpiece directly onto the skins
surface, thus transferring energy in a process that is not chromophoredependent.
At high-energy settings, thermal injury reaches the papillary dermis and
extends up to 11.8 m in depth below the dermal-epidermal junction. In
late 2008, the company that produced the only plasma device on the market
stopped its production. At the time of writing this chapter, the handpiece
nozzles necessary for the plasma treatments were unavailable.
INDICATIONS
Both the lasers can be used for numerous indications though as a thumb rule
deep dermal, vascular and lymphatic conditions respond best to pulsed CO2
lasers (Table 2.4).
Skin Lesions
Epidermal lesions (e.g., junctional nevi, trichoepithelioma, solar keratoses,
seborrheic keratoses, and sebaceous hyperplasia) respond extremely well
to the erbium:YAG laser. Dermal lesions (e.g., compound nevi, dermal nevi,
syringoma, xanthelasmas) can be modified and the exophytic component
removed, producing an improved cosmetic appearance, with both the
lasers. However, where there is a deeper dermal component, these lesions
will inevitably recur. Pulsed CO2 lasers may be used in dermal disorders. In
certain disorders where sensitive and thin areas of skin are involved, like in
Zoons balanitis, Er:YAG is probably an ideal tool to use.
Table 2.4 Indications of ablative lasers
Focal treatment
Epidermal disorders
Actinic cheilitis
BXO (balanitis xerotica obliterans)
Epidermal nevi
Epidermal tumors
Lichen sclerosus
Melasma
Seborrheic keratoses
Verruca
Zoons balanitis
Dermal disorders
Benign dermal tumors

Lymphangiomas
Scars
Vascular growths
Resurfacing mode
Wrinkles
Scars
The atrophic scars, most responsive to resurfacing, are those that are relatively
shallow, soft and distensible. Extremely deep scars or pits bound with highly
fibrotic tissue are far less responsive to either type of resurfacing.
Acne
Both the pulsed CO2 and the erbium:YAG laser are useful for treating acne
scars, but results with any resurfacing procedure alone are moderate at best.
A combined approach to acne scar improvement produces the best results.
TCA cross can somewhat help in ice-pick scars and deep boxcar scars.
Dermarollers help the rolling scars and superficial boxcar scars the results of
which are probably similar to the results of fractional lasers.
Post-traumatic/Chickenpox Scars
Posttraumatic and surgical scars may be modified by the Erbium:YAG/CO2
laser if resurfacing is performed during the phase of collagen remodeling
(i.e., within 90 days of the original trauma or surgery). Linear facial scars
respond best. Extrafacial scars respond poorly. Raised scars can be planed
down to the level of the surrounding skin (Fig. 2.7A). Most depressed scars
require a sculpting approach where the edges are ablated till they are leveled
Figs 2.7A and B: (A) Ablative lasers can ablate the elevated surface of hypertrophic
scars; (B) Ablative lasers use in depressed scars. The elevated edges are planed down
to the level of the adjacent epidermis skin
Ablative Lasers 41
with the surrounding skin (Fig. 2.7B). A pass over the center of the scar can
help to stimulate collagen to lift up the scar.
Dyspigmentation
Pigmentation of the skin due to sun damage or chloasma can respond to the
Erbium:YAG laser. The so called Erbium peel is effective in fair skinned and
South east Asian skin types. Chloasma does tend to recur, so the use of longterm bleaching preparations and ultraviolet A light-blocking sunscreens is
mandatory.
Wrinkles
Although the Erbium:YAG laser has been specifically promoted for the
treatment of superficial wrinkles, it can successfully remove both superficial
and deeper wrinkles with great accuracy. Treating deeper wrinkles leads
to dermal bleeding, which makes the procedure slightly cumbersome and
messy. CO2 and Er:YAG are not effective in effacing movement-associated
rhytides in the glabellar region and the nasolabial folds. Thus, wrinkles caused
by excessive ultraviolet light exposure are primarily indicated for resurfacing
with either laser, those associated with movement are secondarily indicated.
TREATMENT
Preoperative
Patient Selection
Oral retinoid therapy: Patients who are taking oral retinoids (e.g.,
isotretinoin) may have delayed healing and atypical scarring if resurfacing is
performed while they are taking the drug. Although the safe time period for
performing resurfacing after cessation of oral retinoids is not known, most
experts would wait at least 6 months.
Lack of skin appendages: Because the skin reepithelializes by means of the
appendages after laser resurfacing, extensive destruction to appendages (e.g.
electrolysis, burns, etc.) may cause delayed healing and scarring.
Viral diseases: Erbium:YAG resurfacing produces significant plume. Live
viruses may be a hazard to operating room personnel and other patients. It
may be hazardous to treat patients with Hepatitis-B, Hepatitis-C, or HIV with
erbium laser resurfacing.
Smoke Evacuation
During the treatment with the Erbium laser, a distinct dust and smoke
formation must be expected due to the photoablation. The particles and
aerosols being emitted are evacuated through the handpiece. Without a
smoke evacuator, the optical part of the handpiece can be damaged due to
the deposition of the particles.
Anesthesia
The local anesthesia should be varied according to the depth of treatment.
There are several forms to choose from: surface anesthesia, applied topically
and occlusively (EMLA) or infiltration anesthesia (aminoamides, aminoester)
that is injected intradermally or subcutaneously. It is also possible to apply
infiltration anesthesia topically after the ablation of epidermis.
Medication
Initiate Levofloxacin 750 mg a day before the surgery and continue it for 5
days. In case there is a history of herpes labialis, Famciclovir 250 mg TDS is
also started.
Intraoperative
Principles
The goal of both CO2 and erbium laser resurfacing is clean, char-free, layerby-layer ablation of skin, resulting in the absolute or relative effacement of
lesions, while avoiding the creation of dermal injury so deep that hypertrophic
scarring or other untoward complications result. Penetration into the
papillary or upper reticular dermis represents the endpoint of safe treatment.
Several factors determine the actual treatment parameters for each laser
system, including the anatomic location being resurfaced, the patients skin
type, individual tissue response to irradiation and prior treatments to the
area.
In general, highly fibrotic areas, skin with more severe lesional
involvement and facial regions with thicker skin-the cheeks, chin, perioral
area and forehead-require higher fluences and a greater number of laser
passes. However, thin or delicate skin, such as that in the periocular area, or
skin with fewer adnexal structures as a result of prior treatment requires lower
energies and/or fewer passes. Moreover, patients with darker skin phototypes
(III and above) run an ever-greater risk of adverse pigmentary changes as the
depth of ablation increases. Thus, the aggressiveness of treatment should
always be case-specific.
The surgeon should use energy densities equal to or exceeding the
critical irradiance threshold (5 J/cm2) for tissue ablation when using either
system. Lower irradiances on the contrary heat the tissue too slowly, thereby
permitting greater heat conduction into surrounding tissues. Excessively
deep thermal injury, or even charring, can result.
Ablative Lasers 43
Techniques
When performing resurfacing with the erbium:YAG laser, a homogeneous
appearance must be obtained to produce an acceptable aesthetic result.
The laser tissue interaction produces ablative effects with sharp edges, as
compared with the carbon dioxide laser and its gaussian curve. To ensure
a homogeneous appearance, significant (i.e., 30 to 50%) overlap of pulses is
necessary. Smooth skin lesions can be ablated by applying over-lapping laser
spots to the area to be treated. The overlapping best adapted to the beam
profile is 10 to 20% of the spot diameter. Of course, it is possible to work with
a higher overlap but it has to be taken into consideration that energy may
summate in the overlapped areas. Lower pulse energies have to be selected
in this case. Overlap less than 10% is not recommended since ablation may
be not as regular as usual. Uneven skin lesions can be treated by smoothing
the entire treatment area and then flattening the edges of wrinkles or other
lesions in a second pass. There are three techniques that are recommended
for ablative lasers (Fig. 2.8).
Types of Resurfacing Techniques

Circular Technique
In this a overlap technique is used to flatten edges of lesion (e.g. acne scars)
(Fig. 2.8).
Fig. 2.8: Standard techniques employed while using ablative lasers
Paintbrush Technique
Paintbrush technique is used for extensive lesions (e.g. lentigines, Beckers
nevi). After finishing one pass, the direction should be changed by 90 degrees.
If further passes are required, they should be given diagonally (Fig. 2.9). The
ultimate aim is to avoid excessive thermal damage.
Single Spot Technique

This technique is for a single lesion (e.g. syringomas). The method that is
used for layering passes is important (Fig. 2.8), as it ensures less overlap and
consequentially minimal thermal damage.
End Points
Er:YAG
When resurfacing with the Erbium:YAG laser, clear visualization of the end
points makes the procedure extremely accurate. Using magnifying glasses
/Dermaview helps in assessing the end point. Because little necrotic tissue
remains after erbium laser impact, wiping the skin between passes is not
typically necessary, as it is after CO2 irradiation.
Fig. 2.9: Method of layering of passes with ablative lasers with the aim of avoiding
excessive thermal damage
Ablative Lasers 45
Epidermis: Resurfacing within the epidermis produces a yellowish-brown

appearance on the epidermis. This is preceded by a transient whitening of
the skin.
Epidermal-dermal junction: Once the epidermis has been removed, the
pinkish appearance of the upper papillary dermis will be readily appreciated
(Fig. 2.10). The follicle openings look small and regular, like a fine sponge.
Lower papillary dermis: As resurfacing proceeds into the papillary dermis,
pinpoint bleeding and a transudate develops, indicating injury to the small
capillaries that are present in the papillary dermis. If local anesthesia with
epinephrine is used, bleeding and transudation may be greatly reduced
(Fig. 2.11). Follicle openings become wider and begins to stand out from the
surrounding dermis.
Upper reticular dermis: When the upper reticular dermis is reached,
bleeding may become splotchy, and the transudate becomes more profuse.
Follicle openings become much wider and the collagen bundles become
coarser and more haphazard in orientation. At this point, it is generally best
to proceed no further.
Although the endpoints are clear, especially with the help of magnification,
they may take several seconds or minutes to become evident.
Fig 2.10: A case of Beckers nevi treated with Er:YAG resurfacing, the pinkish hue of
papillary dermis is the end point (Er:YAG, Ascepelion; 10 J/cm2; 4 Hz)
Fig. 2.11: A case of junctional nevus with pin point bleeding and the end point of
prominent follicular openings (Er:YAG 7 J/cm2; 4 Hz; level: lower papillary dermis)
CO2 Laser
The first pass with a CO2 laser will vaporize all or most of the epidermis.
Because CO2 ablation is primarily thermal, each pass will leave behind a
detritus of coagulated necrotic tissue. This whitish debris must be thoroughly
removed with saline-soaked gauze; if allowed to remain, it can act as a heat
sink and promote excessive thermal damage with successive laser passes.
Moreover, the removal of necrotic tissue allows better visualization of the
surgical field. After the debris left by the first pass has been removed, the
smooth, pink surface of the papillary dermis is apparent. With each subsequent
pass, subtle color changes signal deeper dermal penetration. Collagen fibers
appear as white, cotton-like threads. A change to a distinctly yellowish color,
apparent when the surgeon reaches the upper reticular dermis, which signals
the endpoint of treatment, even when lesions have not been fully effaced. As
discussed above these end points are not always reliably seen.
Continued ablation and possibly greater residual thermal injury,
could substantially injure the adnexal follicular structures essential for
reepithelialization. In general, the thin skin of the periorbital region can
sustain one to two passes with the CO2 laser, whereas the thicker skin of
other facial regions can tolerate three or four passes. More than four passes
does not seem to improve clinical results and is not advised because tissue
vaporization is reduced and progressive desiccation of the dermis occurs,
which may cause excessive residual thermal injury.
Dosage and Settings

A rough guide to dosages is given in the Appendix but a useful method is to
understand the end points to be achieved which are detailed above. An atlas
is appended that details common procedures.
Ablative Lasers 47
Wound Care
Dressings
In the area of resurfacing, occlusive dressings were used to absorb the exudate
produced by the procedure. In spot therapy, we prefer a open wound care with
topical fucidin ointment applied thrice a day till the crust falls off. Oral levofloxacin
750 mg HS for 5 days is routinely given to prevent bacterial infections.
Post Wound Care

A mild depigmenting agent, ideally HQ/Tretinoin free, is preferred
(MelacareTM) can be given after the crust has fallen off to avoid PIH. Sun
avoidance is advisable for 10 days after the procedure.
LIMITATIONS OF ABLATIVE LASERS

Er:YAG
On impact, the erbium laser beam forcibly ejects desiccated tissue at
supersonic speeds, hence, the distinctive skin popping during ablation and the
superficially whitened area left behind quickly fades into inconspicuousness,
offering the surgeon less guidance when treating large adjacent areas of the
dermis than does the coagulated tissue remaining after CO2 irradiation.
The Erbium: YAG laser is absorbed superficially in the skin due to its
high water absorption. Higher fluences and multiple passes are necessary to
obtain improvement in deeper wrinkles and acne scars, making the procedure
slower than with the carbon dioxide laser. To overcome this problem, large
scan patterns and higher fluence erbium machines have been developed.
Bleeding: When deeper resurfacing is being performed, dermal bleeding
will occur, making the procedure more cumbersome and messy. Modulated
lasers can help in increasing the coagulative potential of the lasers. Noise
level: Because the erbium laser tissue interaction is strong and explosive,
the noise level in the operating room can become oppressive; ear muffs are
recommended.
Plume: Because significant tissue ablation occurs with the Erbium:YAG
laser, a large amount of plume containing live tissue is released. A powerful
smoke evacuation system is needed to cope with the plume. Live viruses are
a potential problem for operating room staff.
CO2 Lasers
The major issues are due to the large degree of thermal damage that is
caused by the systems. This can lead to postoperative erythema, scarring and
pigmentary alterations specially in pigmented skins.
CONCLUSION
The use of modulated Er:YAG lasers (Box 1) has tried to bridge the gap
between ablative/coagulative potential of CO2 and the fine ablation with less
coagulative potential of Er:YAG. In most dermatological indications, we feel
that, the less thermal damage and fine ablation makes the Er:YAG a better
technology. The added advantage of less side effects (PIH) makes it useful in
Indian skin.
Ablative Lasers 49
APPENDIX
Table 1 Treatment guidelines for Pulsed CO2
Indications
Energy
Diameter
(mm)
Exposure
time
Comments
Spot Vaporization
Benign skin
tumors
Condylomata
acuminate
Epithelial
dysplasia
Verrucae Vulgaris
810-(20) Watt
0.52-(3) mm
0.10.2 s
This is the superpulse

mode which has
a higher thermal
damage than the
ultrapulse mode.
Usually a controlled
single pulse is given
ranging from 0.01-0.09
sec
Large Area
Vaporization
Condylomata
acuminate
Epithelial
dysplasia
Verrucae
510 Watt
0.51.5 mm
0.1 s
Either the superpulse

mode or the repeat
mode can be selected
with a 0.4s Interval
Ultrapulse Mode
BCC
Flat benign
Scars
SCC
Skin ablation
Skin tumors
1020 Watt
Fixed with
scanner
<1ms
The least thermal

damage amongst all
the modes of CO2
lasers
Surgical
Resection
1525 Watt
0.51 mm
Continuous
wave
The ablation and

thermal damage is the
maximum
Table 2 Treatment guidelines for Er:YAG laser

Indications
Diameter (mm)
Energy
Pattern
Comments
Acne scars
3-5 according to
lesion size
45 J/cm2
Circle
Plane acne scars

edges with
overlap
technique
Becker nevi
Caf-au-lait
spots
3-5 according to
lesion size
45 J/cm2
Paintbrush
With darker skin

types, transitory
hypo/hyper
pigmentation
possible
(inform patient!)
continue the
treatment until
no more pigment
is visible
Contd...
Contd...
Indications
Diameter (mm)
Energy
Pattern
Comments
Epidermal nevi
(soft)
35 according to
lesion size
45 J/cm2
Paintbrush
Ablation down
to the level of the
skin or into the
unaffected dermis
(until whitish tissue
of dermis becomes
visible)
Exophytic scars
(flat scars,
no keloids)
35 according to
lesion size
45 J/cm2
Paintbrush
Ablation of
exophytic portion
Lentigines spilus
36 according to
lesion size
45 J/cm2
Single Spot
(selective)
Paintbrush
(area)
The treatment is
continued until no
more pigment is
visible
Stepped scars
36 according to
lesion size
45 J/cm2
Overlap
Plane the edge of

the scar
Syringomas
Xanthelasmas
Adenoma
sebaceum
36 according to
lesion size
45 J/cm2
Single Spot
Requires ablation
of the complete
lesion (trough
shaped depression)
Wrinkles
13 according to
lesion size
45 J/cm2
Overlap
Plane the shoulder

of the wrinkle
BOOKS
1. Willard RJ, Moody Br, Hruza GJ. Carbon dioxide and Erbium:YAG laser ablation.
In: Goldman MP (Ed). Cutaneous and Cosmetic Laser Surgery, 2nd ed. USA,
2009.
2. Carcamo AS, Goldman MP. Skin resurfacing with Ablative Lasers. In: Goldman
MP (Ed). Cutaneous and Cosmetic Laser Surgery, 2nd ed. USA, 2009.
BIBLIOGRAPHY
1. Alster. Cutaneous resurfacing with CO2 and Erbium:Yag laser. Plast Reconstr
Surg. 1999;103:619-32.
2. Alster TS, Nanni CA, Williams CM. Comparison of four carbon dioxide resurfacing
lasers. A clinical and histopathologic evaluation. Dermatol Surg. 1999;25(3):1538, discussion 159.
3. Alster TS. Clinical and histologic evaluation of 6 erbium: YAG lasers for cutaneous
resurfacing. Lasers Surg Med. 1999;24:87-92.
4. Jaisn ME. Achieving Er:YAG superior resurfacing results with the Er:YAG lasers.
Arch Facial Plastic Surgery. 2002;4:262-6.
5. Fitzpatrick RE, Tope WD, Goldman MP, et al. Pulsed carbon dioxide laser,
trichloroacetic acid, Baker Gordon phenol, and dermabrasion: A comparative
Ablative Lasers 51
clinical and histologic study of cutaneous resurfacing in a porcine model. Arch
Dermatol. 1996;132:469-71.
6. Kauvar AN, Waldorf HA, Geronemus RG. A histopathological comparison of
char-free carbon dioxide lasers. Dermatol Surg. 1996;22(4):343-8.
7. Kim S. Treatment of acne scars in Asian patients using a 2,790-nm fractionalyt
trium scandium gallium garnet laser. Dermatol Surg. 2011;37(10):1464-9.
8. Ross EV, Swann M, Soon S, Izadpanah A, Barnette D, Davenport S. Full-face
treatment with the 2790-nm erbium:YSGG laser system. J Drugs Dermatol.
2009;8:248-52.
9. Weinstein C. Carbon dioxide laser resurfacing. Long-term follow-up in 2123
patients. Clin Plast Surg.1998;25(1):109-30.
ABLATIVE LASER TREATMENT OF COMMON CONDITIONS

Even with the advent of novel laser systems, the popularity of Er:YAG and
CO2 has not waned, even though in terms of publications not much has
been published in recent times. It is our opinion that for most epidermal
and dermal disorders, Er:YAG is superior as it has less thermal damage and a
predictable depth, with easy to discern end points. Those who prefer the CO2
laser, should be adept at using the tool to minimize thermal damage.
A useful thumb rule is, that when fine ablation, cosmesis and fast
healing is the goal, Er:YAG is preferred. For deeper lesions, vascular lesions,
lymphatic tumors CO2 laser is preferred. Though variable pulse Er:YAG can
mimic the coagulative effects of CO2, those who do not use this laser prefer
the controlled effect of carbon dioxide laser.
VARIATIONS IN LASER SETTINGS AND TISSUE EFFECT

As CO2 is still the workhorse of most laser practitioners in India we will dwell
on it. It should be appreciated that the conventional pulsed CO2 lasers can
be tweaked to give optimal cogulation and residual thermal damage which
can enable the surgeon to use the laser for varying indications with minimal
damage.
Most lasers have three options Cw (continuous wave), R mode (repeat
mode) and S mode (Single mode). It should be remembered that all three
are essentially Cw modes. Plus there is a superpulsed mode where a train of
pulses are used which approximate the effect of the ultrapulse laser. Possibly
the most important aspect to differentiate them is the pulse duration of the
laser which conventionally has a setting that is in seconds. Thus they start from
0.01 second to 0.99 seconds. This means that the minimum is 10 miliseconds,
thus most lasers used in clinical practice are not ultrapulse lasers.
A basic principle of minimizing thermal damage is to use pulses over
a range of 0.2510 ms (0.01 sec), with a maximum dose of 10 J/cm2. The
various modes are depicted in the Figure 2.12 and are detailed below.
High Power Density (PD), Short Exposure Time (Resurfacing mode)

Ideal: Ultrapulse Mode (Fig. 2.13A)
Principle: The aim of the therapy is to reduce the zone of thermal damage
which is the result of both: (1) Subablative localized energy densities (at
the base of the wound, as the beam is rapidly attenuated) and (2) Heat
conduction during and after the pulse. This is usually done best by ultrapulse
lasers where the pulse duration is <1 ms.
First pass: The entire epidermis is ablated with a uences of 58 J/cm2 with a
1 ms (0.001s) domain laser, the depth of ablation is 1040 mm.
Ablative Lasers 53
Fig. 2.12: A comparison of the various modes of CO2 lasers with their tissue effect.
(A) Ultrapulse Mode; (B) Cw Repeat/Vaporization Mode; (C) Cw Repeat mode (more
thermal damage); (D) Minimum thermal damage (low fluence, low pulse duration)
Fig. 2.13A: High power/short exposure (450 s) UltraPulse mode. Indication: All
epidermal and most dermal disorders
At this point, the epidermis is normally wiped away with wet gauze, and
the papillary dermis is exposed. However, there is a case to be made for not
wiping. If one knows the extent of the injury after one pass and is condent
that this level of injury will successfully reverse the skin pathology, wiping
only serves to increase patient discomfort and prolong healing. More
importantly, there appears to be a level of dermal thermal injury beyond
which long-term hypopigmentation is almost inevitable in selected patients,
especially appearing along the lateral cheeks and extending to the jawline.
Thus, one can titrate the injury according to the level of desired injury with
one pass if one reliably knows the laser end points.
Second Pass: With the CO2 laser, once the denatured friable epidermis
is wiped off, it takes many pulses to ablate the residual acellular dermis.
With the typical Gaussian beam of the CO2 laser, there will be some
ablation at 7 J/cm2 average uence at the center of the spot, but very little
at the perimeter. Overall, using this average uence, the ablation is about
1015 m per pass. As the average uences reach 10, 15, and 20 J/cm2, the
relative ratio of ablation to tissue heating will increase. That is, roughly the
same RTD will result, but the amount of ablation per pass will increase.
What to look For?

Depending on the patients pathology and age, one sees different surface
characteristics after wiping the denatured epidermis.
Younger Patient: For younger patients with modest photodamage, normally
a pink to red dermis is exposed.
Older patient: For an older patient with severe solar elastosis, one sees
yellowing immediately.
LowMedium Pulse Duration (PD), Long

Exposures in Cw (Defocused Mode)
Ideal settings: 510 J/cm2, 50 ms (0.10 sec1 sec) (Fig 2.13B)
Cw (repeat mode)
Principle: This is the so-called vaporization mode, which is actually a
combination of simultaneous heating and vaporization. Most conventional
CO2 lasers can be used in this mode. As normally the lasers are kept at a
distance that is beyond the focus length, thus it is called as defocused mode
Use: This is is used for treating warts and other exophytic lesions where
some tissue heating at the base of the wound is tolerated. Usually, one will
encounter vaporization at the center of the spot and charring at the periphery.
Method: To decrease char, one must move in a pirouetting motion so that
the char is not continuously heated. When the CO2 laser burns a hole in the
skin, the mechanism for ablation is the rapid conversion of water to steam. In
the epidermis, the fragility of this layer provides for easy ablation, as the water
vapor easily escapes the intracellular space, typically carrying with it a solid
Ablative Lasers 55
Fig. 2.13B: Sequence of tissue change due to Cw CO2 set in a defocused

vaporization mode (8 J/cm2; 0.51 sec)
residue of exploded cells. This debris will continue to be heated as it is carried

off, thus one sees burning or combustion. The sequence as proposed by
Verdaasdonk et al. is shown in Figure 2.13B, which explain the tissue effect
of CO2 lasers.
1. Initially, there is slight tissue discoloration. Coincident with a pop, the
surface lifts suggesting boiling bubbles underneath. The sound is due to
the rapid ejection of air through the ablation front (nozzle effect), like
bursting a balloon.
2. This is followed by a small black spot in center of the beam, due to the
carbonization of the dehydrated tissue. Within a few tenths of a second,
this charred zone expanded and a ring is formed.
3. Next, the char combusts, unveiling a new hydrated surface.
4. Then there are cyclical rings of carbonization and vaporization,
following each other in rapid succession as a progressively deeper crater
was formed.
Lower PDs with Long Exposure Times

5 J/cm2, 0.51 seconds (Fig. 2.13C)
Cw (Repeat Mode)
The char is never blown off (either by vaporization of water below the char
or by combustion), and there is deep heating beneath the skin surface.
Indeed, this can be observed occasionally in the treatment of warts and
rhinophyma, where prolonged application times of 0.51 s can result in a
Fig. 2.13C: Low Power (<6 J/cm2; high exposure >0.10 s) leads to more coagulation
Use: Lymphatic, vascular tumors
brownish color and nally deep blackening of the surface. With increased
blackening, the char acts as a nearly perfect absorber, and the char becomes
hotter and hotter. This is why using lower PDs for prolonged periods are
usually not advisable, as it simply results in very deep invisible tissue
heating. It is advisable in these cases to wipe the char, thus exposing hydrated
tissue, so that additional vaporization can take place.
Very Low PDs and Short Exposures

Cw (Single pulse, super pulse mode) (Fig. 2.13D)
Principle: Although the thermal gradient is not steep, that is, the temperature
decay as a function of depth is small, there is so little total heat that this is safe
as long as one pass is made, and this application will typically restrict Residual
thermal damage (RTD) to the epidermis and supercial papillary dermis. The
goal is to use short bursts of subablative PDs to heat a specic thickness of
tissue. In the case of dermatosis papulosis nigra (DPN), for example, one can
heat the tissue just to a level similar to that of the hyfercator. The end point is
slight whitening of the tissue. This technique is best reserved for those who do
not have access to a pulsed CO2 laser.
Use: It is useful in lentigos and mild photodamage.
Settings: With this technique (also known as thermabrasion), the laser is
used in low power mode at 15 W with a defocused beam with very short
bursts of Cw radiation.
An overview of the principles enshrined are depicted in vivo in figure
2.13E in a case of epidermal Nevi.
Ablative Lasers 57
Fig. 2.13D: Low Power (<6 J/cm2; low exposure <0.10 s). Less thermal damage, fine
ablation
Fig. 2.13E: A depiction of various tissue effects based on the pulse duration and dose
(A) 3 J/cm2; 0.01 sec (whitening effect); (B) 3 J/cm2; 0.40 sec (coagulation); (C) 9 J/cm2;
0.50 sec
High PDs with Small Spots (0.10.3 mm)

Cutting Mode: Used in incisions. Most skin surgeons do not use the CO2 laser
in cutting mode, with the exception of eyelid surgery.
Use
The indications for using CO2 for cutting regardless of the mode, include:
Bleeding disorders
Where epinephrine is not indicated
Vascular lesions (hemangiomas and scalp tumors)
Infected surgical sites
In patients with pacemakers or implanted debrillators
Disadvantages
In addition to the cumbersomeness of using the laser as a cutting tool
including the need to work around the articulated arm, the need for a smoke
evacuator, and the constant vigilance that is required not to inadvertently
strike an innocent bystander target, the laser cannot be endorsed as a rst
choice for incisions because healing is delayed compared with scalpel
incisions. It is therefore not recommended for most routine skin surgeries.
Advantages
The advantages, on the other hand, are ease of excision and a relatively
bloodless eld. The lack of perfect hemostasis is partly explained by the
paucity of residual thermal damage (RTD) in a standard excision with CO2
laser. Because the small spot sizes of 0.10.3 mm allow for high PDs, thermal
damage is minimal. Microscopically, one nds 90 mm of basophilic change
and 100500 mm of lateral glassy hypereosinophilic change on routine
staining. It follows that the high-ow vessels larger than 500 mm are likely
to bleed after CO2 transection. In contrast, without blood ow, vessels up
to 2 mm have been coagulated One should note that minimizing RTD and
achieving hemostasis are antagonistic. Ideally, one should choose the laser
parameters with the least RTD that still achieves adequate control of bleeding.
The amount of bleeding vs other modalities such as diathermy and scalpel
has been compared, and it appears that the CO2 laser performs as well as a
cutting electrosurgical current. Another purported advantage of the CO2 laser
is that it seals nerve endings, which presumably results in less postoperative
pain than scalpel excision.
TECHNIQUE PEARLS
Cw Vaporization
In review of the Cw applications described earlier, it becomes clear that
most CO2 laser surgeons somewhat arbitrarily choose the power and
Ablative Lasers 59
pulse duration. Typically, the surgeon repeats the cycle of irradiation and
inspection, continuing until almost or no lesional tissue remains. Fleiming
and Brody proposed a more logical approach to the treatment of lesions with
the Cw CO2 laser. They cited several limitations in the empirical techniques
commonly employed:
1. In many cases, the surgeons dependence on visual differentiation of
normal from lesional tissue leads to possible overtreatment and scar, or
undertreatment and rapid recurrence.
2. This tecnique is slow, because the cycle is repeated for each lesion.
In Fleming and Brodys study, they used a constant power in plotting
the depth of the resulting crater as a guide in planning treatments. They
noted that crater depth depended on uence for the powers used (518
W and 1 mm spot). They found that the application time determined
the crater depth for constant power and spot size. For example, a 10W
pulse delivered with a 1 mm spot and application time of 1 s, can
achieve a depth of 2,500 mm.
Cutting Mode
The reader should note that 1525 W will give a cutting depth of 35 mm with
a hand movement rate of 1.5 mm/s with a 0.3 mm spot. Also, wet gauze should
always be used as a backstop so that the beam does not injure unintended
targets.
Bibliography
1. Fleming MG, Brody N. A new technique for laser treatment of cutaneous tumors.
J Dermatol Surg Oncol. 1986;12(11):1170-5.
2. Verdaasdonk RM, Borst C, van Gemert MJ. Explosive onset of continuous wave
laser tissue ablation. Phys Med Biol. 1990;35(8):1129-44.
INDICATIONS OF ABLATIVE LASERS

The use of ablative lasers and its widespread appeal lies in the fact the water is
the chromophore, and thus almost every skin lesion is a potential target. The
clinicians must choose indications based on the shallower tissue effects due
to higher water absorption of Er:YAG and the deeper effects of CO2. As there is
little selectivity, it is primarily based on how precisely the block of ablated or
heated tissue responds to the laser. These lasers are the classic what you see
is what you get laser as the injury is always top to bottom. Obviously the CO2
laser demands a high level of operator practice and skill to achieve reliable
results. It follows that with greater use, one nds that the laser is as good or
nearly as good as some of the pigment selective or vascular selective lasers
for particular lesions.
As a general rule the principles enshrined in Figure 2.13 are to be followed,
thus where one needs selective single spot damage a low fluence and pulse
duration should be used and where there is a need for coagulation or ablation
the pulse duration and dose should be increased.
The indications range from the A to Z of dermatology with almost one
condition for each alphabet! But before attempting any laser procedure three
questions must be asked.
1. Is there a need for a laser ablation ?
2. What are the chances of recurrences ?
3. How should the laser be used ?
Though we will largely focus on the last aspect there are numerous
indications where lasers are of little use and are best left alone as the ultimate
cosmetic results may be worse than the initial appearance.
1. Scars
a. Acne/Chickenpox Scars
Modest improvement of mild to moderate acne scarring can be achieved
with the short pulsed Er: YAG laser resurfacing. Deep acne scars have a better
chance of improvement when resurfaced with a modulated Er:YAG laser.
However, even with the modulated Er:YAG lasers, the reported improvement
has been moderate at best. Adjunctive treatment with other modalities
(e.g. subcision, punch excision, fillers, grafts) is usually required to achieve
significant correction of this difficult-to-treat condition.
Though fractional lasers are used in acne scars for localised scars like
chicken pox scars ablative lasers are superior to most fractional lasers.
The basic principle being, reducing the depth of the scar borders and
stimulating neocollagenesis to fill in the depressions.
Step By Step Approach

Spot laser resurfacing (Fig. 2.14A)
Ablative Lasers 61
Fig. 2.14A: A figurative depiction of laser treatment of atrophic chicken pox scar
1. First the area around and over the scar is vaporized with one laser pass
De-epithelialization typically requires one pass with the CO2 laser at
300mJ and two to three passes with the Er:YAG laser at 5 J/cm2.
2. Additional passes are made along the edge of the scar.
The purpose is to sculpt the scar edges or shoulders with additional
vaporizing laser passes to bring the edge to approximate the level of the
base. This is followed by 12 passes in the center of the scar. Aggressive
passes over the center can cause a deeper scar. Partially desiccated tissue
should be completely removed with saline- or water-soaked gauze after
each laser pass in an effort to prevent charring.
3. End point: Effacement of the scar or bringing the surrounding skin to
the level of the depth of the scar.
Weinstein et al rst attened the shoulders of the scars by single
spots at 8 J/cm2, two to ve passes, followed by treatment of the entire
anatomical unit with the computerized scanner at 15 J/cm2 and 30%

pulse overlap with two to three passes. For deeper acne scars, she used
the CO2 laser (SilkTouch scanning device, 3040 J/cm2) for the shoulders
followed by the Er:YAG laser as described before. Using this technique,
she achieved, seven good (7090% improvement), and three fair results
(5070% improvement).
A depiction of a case of chickenpox scar treated by Er: YAG laser is
given if Figure 2.14B.
Pearls/Pitfalls
1. Never ablate an atrophic scar in toto as it invariably leads to a deeper
scar.
2. Vary the spot size to adjust the beam to target the edge of the scar.
3. Non ablative resurfacing and fractional lasers do not help substantially
in chickenpox/small pox scars.
4. Subcision is usually of no use as these scars are tissue defects and not
tethered unlike rolling scars of acne.
Level of Difficulty
High.
b. Post-traumatic and Surgical Scars (Elevated Scar)

When performed during the phase of collagen remodeling (i.e. within 90 days
of the original trauma), Er:YAG laser resurfacing can significantly improve
the cosmetic appearance of post-traumatic and surgical scars. Linear facial
scars tend to respond the best.
ii
Fig 2.14B: (i) A case of chicken pox scar, the medial scar was treated with a Er:YAG
laser; (ii) after 6 months marked improvement is seen in the treated scar as compared
to the control (lateral) scar
Ablative Lasers 63

Spot Laser Resurfacing (Fig. 2.14C)
1. An elevated scar can simply be sculpted down to the level of the
surrounding skin.
2. A few passes over the center of the scars can depress it further.
Combination Approach
1. Initial sessions can be done with a PDL in the erythematous stage, this
tends to cut off the vascular supply.
2. Concomitant topical agents can be used.
3. Treat a scar early.
Level of Difficulty
Easy.
2. Acne Keloidalis Nuchae

There are two approaches to treat this condition. One is to target the hair
growth and second is to ablate the lesion. The former is slow and is rarely
successful in our experience. Ablating with the CO2 laser, leads to better
results. Recurrences ensue unless the lesions are vaporized down to the fat
and the hair follicles are destroyed. But the larger vessels (>0.5 mm ) leads to
profuse bleeding that requires cogulation by electrosurgery
Kantor et al. treated eight patients with the CO2 laser and found that as long
as the lesions were excised to the level of the fat, there were no recurrences.
Lesions were allowed to heal by secondary intention. The primary advantage
Fig. 2.14C: Laser treatment of elevated scar
of the use of CO2 laser in acne keloidalis nuchae is hemostasis vs the lack of
the same in cold steel surgery.
Level of Difficulty
High.
Bibliography
1. Dragoni F, Bassi A, Cannarozzo G, Bonan P, Moretti S, Campolmi P. Successful
treatment of acne keloidalis nuchae resistant to conventional therapy with 1064nm ND:YAG laser. G Ital Dermatol Venereol. 2013;148(2):231-2.
2. Esmat SM, Abdel Hay RM, Abu Zeid OM, Hosni HN. The efficacy of laser-assisted
hair removal in the treatment of acne keloidalis nuchae; a pilot study. Eur J
Dermatol. 2012;22(5):645-50. doi: 10.1684/ejd.2012.1830.
3. Kantor GR, Ratz JL, Wheeland RG. Treatment of acne keloidalis nuchae with
carbon dioxide laser. J Am Acad Dermatol. 1986;14(2 Pt 1):263-7.
3. Actinic Cheilitis
Though both the ultrapulse and the Cw laser have been used, we feel that
a adequately gated Cw laser can give results comparable to the ultrapulse
lasers
Step By Step Approach (Fig. 2.15)

1. Cw mode of CO2 power 3 to 8 W using defocused, 24 mm beams is
used.
2. End point: After the rst pass in Cw mode white bubbling of the surface
(opalescence) is seen. This can be wiped away with either saline-soaked
gauze or hydrogen peroxide. If there is a mildly damaged area, a bright
pink papillary dermis is exposed. However, in areas where there is severe
actinic damage, one sees a yellow-gray surface.
Some authors have described three colors as end points namely, pink,
white/gray, and white coarse. It was believed that the first two levels
are desirable. But it is now believed that the whiter areas are those focal
areas with the greatest clinical damage prior to treatment and may also
be needed to be removed. The lack of surface pinkness is not only due to
deeper treatment, but also due to pre-existing brosis in these areas, as
well as increased acanthosis and interdigitations between the lesion and
the underlying dermis.
3. An additional pass is performed in this area with a very low power of
about 2 W for 0.51 s.
4. The importance of moving the handpiece in a rapid brushing manner
cannot be overstated. This in the case of Cw mode, the hand becomes
a scanner, limiting the dwell time in a somewhat primitive manner, but
one that becomes increasingly precise and reliable with practice.
Ablative Lasers 65
Figs 2.15A to C: (A) A case of Actinic Cheilitis. Plan: Ablation of the epidermis with
Er:YAG and coagulation of the dermal vessels with pulsed CO2; (B) Note the whitening
due to the tissue effects of Er:YAG; (C) 34 passes leads to bleeding, the desired end
point
Level of Difficulty
High.
4. Rhinophyma
Background
This consequence of rosacea is characterized by sebaceous hyperplasia of
sebum and keratinous debris. Variable amounts of dermal fibroplasia and
connective tissue increase may also occur.
Principle of Surgery/Lasers Used

The goal of surgical management of rhinophyma is to debulk the
hypertrophied tissue and leave an adequate glandular reserve to allow
scarless reepithelization. Many patients request treatment, not for cosmetic
considerations, but to improve air movement.
Many techniques have been used to treat rhinophyma, including
dermabrasion, cold steel surgical sculpting, cryosurgery, electrosurgery,
CO2 laser ablation, and Er:YAG laser ablation. Dermabrasion may result in
incomplete ablation of rhinophymatous tissue due to technical difficulties.
Cryosurgery often results in uneven ablation because it is difficult to achieve

a uniform depth of freezing. Electrosurgical sculpting allows easy tissue
removal but heat conduction to deeper tissues may result in scarring. Lack of
hemostasis with cold-steel surgery for rhinophyma makes this a suboptimal
treatment modality.
CO2 continuous wave laser ablation allows for precision in nasal shaping.
Hemostasis during the procedure allows visualization of the treated areas and
greater control over contouring. The use of prerhinophymatous photographs
helps to prevent oversculpting. Care must be taken, especially at the ala, not
to overtreat, which can lead to scarring and nasal flaring. Consideration of the
residual 12 mm of thermally denatured tissue with the Cw CO2 laser should
be taken into account. There is a definite risk of scarring when ablating to
a deep plane. One must be aware of the extent of ablation by recognizing
sebaceous gland structures as deeper layers of tissue are removed. During
vaporization, the dermis contracts and sebum is visibly expressed from
the sebaceous glands, indicating that scarring is unlikely at this depth. Reepithelialization occurs by approximately 34 weeks with Cw CO2 lasers.
A resurfacing CO2 laser or variable pulsed Er:YAG laser can be used to
treat mild to moderate rhinophyma. Re-epithelialization is complete in
approximately 23 weeks. The risk of scarring with resurfacing lasers is very
low. Some hypopigmentation is often seen and a reduced number of more
prominent pores can also occur. Frank scarring is seen more often when
using Cw lasers.
Step by Step Approach

1. Outline the entire nose with additional markings of the rhinophymatous
tissue.
2. Perform a nasal ring block by infiltrating local anesthetic along the nose
cheek junction to anesthetize the infratrochlear, supratrochlear and
infraorbital nerve branches. Infiltrate local anesthetic at the base of the
collumella and finally inject anesthetic at the nasal bone and cartilage
junction to the left and right of midline to anesthetize the anterior
ethmoidal nerves. This should provide complete nasal skin anesthesia
and obviate the need for extensive painful injections into the often stiff
rhinophymatous tissue.
3. Wrap the nose with wet towels and cover the patients eyes with wet eye
patches.
4. Ablate the rhinophymatous tissue until the nose shape approximates
that of its prerhinophymatous state (compare with the before
photographs). With resurfacing lasers, maximal energy fluences and
pulse rates, along with pulse stacking, will be needed to achieve sufficient
ablation. Although it has been advocated that, for severe rhinophyma,
it may be advantageous to first use the Cw CO2 laser with a small spot
Ablative Lasers 67
size to excise and debulk large phymatous areas followed by the use of a
larger spot size for vaporization and fine contouring. It is advised not to
cut away the rhinophyma nodules with the laser in the focused mode as
we have found that areas so treated heal with scarring.
5. Ablation should stop while still in the sebaceous tissue plane. Once
large vessels have been encountered or there is no more sebaceous
tissue noted ablation has proceeded too deeply and those areas will be
at increased risk for scarring.
6. It is better to err on the side of under-treatment rather than overtreat
ment.
7. Consider the anticipated postlaser treatment coagulated tissue slough
and tissue contraction due to post-treatment fibrosis.
8. Special care should be taken at the nasal ala groove where too deep an
ablation can result in unattractive nasal flaring.
9. Feather the treatment area by ablating into the papillary dermis the rest
of the nose.
Pitfalls/Pearls
Hemostasis is achieved with lidocaine with epinephrine soaked gauze.
Larger vessels that cannot be coagulated with the laser are sealed with spot
electrocoagulation.
In Indian skin the high level of PIH makes such procedures uncommon.
A modulated Er:YAG is a better tool in our opinion.
Level of Difficulty
High.
5. Nevi (Epidermal and Dermal)

Almost all types of epidermal and dermal nevi can be treated and thus we will
discuss a few representative conditions in detail. As a general rule deeper the
lesions, poorer are the results.
a. Epidermal Nevi
Background
Epidermal nevi are developmental abnormalities resulting in excess
keratinocytes. Lesions usually manifest early in life and have a predilection
for the neck, trunk and extremities. While tumors, such as basal cell
carcinoma and squamous cell carcinoma have been reported to arise within
these lesions, this is a rare occurrence and removal is primarily of a cosmetic
nature in such nevi.
Laser Used
Excision is usually not an option due to the large size of many epidermal
nevi. Laser ablation with CO2 or Er:YAG lasers can successfully remove these
lesions.
The Er:YAG can be used but the dermal bleeding is a issue even with
the novel modulated lasers.The CO2 laser may be combined with pigment
targeting lasers to decrease the risk of scarring. The CO2 laser is used to first
ablate the clinically visible epidermal nevus followed by treatment with the
frequency doubled Q-switched Nd:YAG laser at 3.5-4.0 J/cm2. A combination
with fractional CO2 has been published recently. The same principles can be
used to treat nevus comedonicus and PEODN (Fig. 2.16).
Though other lasers like PDL, Nd:YAG and argon have been tried we do
not use them as the results do not match the results of the ablative lasers.

Care must be taken to balance efficacy versus scarring. Epidermal ablation
only will allow for recurrence of the abnormal keratinization. Excessive
Figs 2.16A to C: (A) A case of Nevus Comedonicus; (B) UltraPulse CO2 laser (260 mJ),
after three passes there is a clean ablation of the epidermis with partial ablation of
the follicular plugs, glistening papillary dermis being the end point; (C) Complete
removal of the follicular plugs
Ablative Lasers 69
ablation will lead to scarring. The ideal depth of ablation is to the papillary
dermis.
1. UltraPulse laser with the 3 mm handpiece and a pulse energy of 450500
mJ.
2. This results in epidermal ablation at the center of the spot, and after
carefully heating the epidermis, the denatured epithelium can be wiped
away (Fig. 2.17A).
3. Use a dermaview to see the altered dermis. Fine papillomatosis can be
seen where the epidermal nevus remains.
4. These lesions requires a reduction of the spot size to a 1 mm handpiece
which is then used to ablate the remaining areas with pulse energies
ranging from 150 to 250 mJ. The handpiece can be focused or defocused
to either heat or ablate the remanant tissue. As the handpiece is moved
closer to the lesion, one increases the uence and a louder pop is heard.
After a few passes, the papillomatosis disappears and the area is smooth
(Fig. 2.17B).
End point: Yellowing of the dermis and loss of papillations.
Pitfalls/Pearls
1. Do not try to achieve complete removal of the lesions as the residual
thermal damage is usually sufcient to obtain long-term remissions
without signicant scaring or pigmentation changes.
2. If properly used a Cw CO2 can achieve results as good as UltraPulse CO2
lasers.
3. A soft nevi will respond better than the hard verrucous nevi.
Level of Difficulty
Moderate to high.
Figs 2.17A and B: (A) An epidermal nevus being treated with the pulsed CO2. Note
the thermal necrosis on the surface; (B) The debris is wiped off leaving behind the
remnant lesions subsequently the spot size is reduced to target the remaining tissue
Bibliography
1. Conti R, Bruscino N, Campolmi P, Bonan P, Cannarozzo G, Moretti S.
Inflammatory linear verrucous epidermal nevus: why a combined laser therapy.
J Cosmet Laser Ther. 2013;15(4):242-5.
2. Hammami GH, Lacour JP, Passeron T. Treatment of inflammatory linear
verrucous epidermal nevus with 2940 nm erbium fractional laser. J Eur Acad
Dermatol Venereol. 2013 Sep 24.
3. Jain S, Sardana K, Garg VK. Ultrapulse carbon dioxide laser treatment of
porokeratotic eccrine ostial and dermal duct nevus. Pediatr Dermatol.
2013;30(2):264-6.
4. Sardana K, Garg VK. Successful treatment of nevus comedonicus with ultrapulse
CO2 laser. Indian J Dermatol Venereol Leprol. 2009;75(5):534-5.
b. Nevus Sebaceous
Principles
The concept and method is largely similar to that of epidermal nevi, but in
our view these lesions are difficult to remove with incomplete removal.
Step by step:
1. The plaques are vaporized with many passes to achieve a level where
most of the yellow papules embedded in the lesion are removed.
2. As there is concomitant bleeding on reaching the dermis a CO2 laser is
ideal for the lesions.
3. The nal end point to be achieved is a smooth pink surface. Healing is by
secondary intention.
Pearls/Pitfalls
Like epidermal nevi, attempts to ablate the lesion down to the reticular dermis
will result in longer remission but also in a greater likelihood of scarring.
Thus its better to use the laser in the defocused mode and remove only the
exophytic portion, as aggressive therapy results in extensive scarring.
Level of Difficulty
High.
c. Melanocytic Nevi
This condition has been discussed at length in the following chapter. It has
been our experience that the use of ablative lasers achieved excellent results.
Our approach is to use lasers depending on the type of the nevi.
Junctional Nevi: Er:YAG laser, end point being complete ablation of the
pigmented lesions.
Ablative Lasers 71
Compound Nevi: Intially a Er:YAG can be used to accurately remove the

visible pigmented nevi. This can be followed by a 12 passes of a CO2 in a
single pulse mode to coagulate the vessels in the papillary dermis. Another
option is to first use a Er:YAG laser followed by a Qs Nd:YAG to destroy the
nevus cells.
Dermal Nevi: Either a Er:YAG or a pulsed CO2 can be used.
A representative depiction is given in Figure 2.18 while a detailed
discussion follows in the next chapter.
6. Benign Tumors
CO2 lasers can be employed to treat a number of dermal growths. Adenoma
sebaceum, trichoepitheliomas, syringomas, hidrocystomas, neurofibromas,
myxoid cysts, sebaceous hyperplasia, syringocystadenoma papilliferum, and
xanthelasma have all been treated with laser ablation. Though the lesions
that are discussed below may seem to be disparate conditions with various
etiologies including eccrine, pilar, sebaceous tumors, cysts and cholesterol
Figs 2.18A to C: (A) A case of a compound melanocytic nevi. Plan to treat with a
ultrapulse CO2; (B) Clean ablation using 250 mJ. Note the lack of thermal damage; (C)
Post-operative appearance after 7 days
deposition disorders, they are discussed here as they are essentially benign,
acquired and largely dermal in nature. Also see Chapter 12 for other
indications.
Principles
1. For individual lesions, the growth is vaporized by using relatively lowpower settings in the 3- to 5-W range with a spot size that matches the
size of the lesion.
2. Though the approach depends upon the depth of the lesion being
treated, the entire lesion should not be destroyed. Ablation should be
carried out but to the level of the dermis since residual thermal damage
will extend 0.5 to 1 mm beyond the level of ablation. Thus one should
not try to remove the entire lesion.
3. If there is deep extension of the lesion recurrence may occur.
4. A useful endpoint is a smooth cutaneous contour matching the
surrounding skin.
a. Adenoma Sebaceum
Er:YAG and Cw and UltraPulse lasers have been used to treat these lesions,
though the latter is better in our opinion.
Settings: One can use the CO2 laser with a low power of 23 W and 12 mm
spot size with short application times of 0.250.5 s to gently vaporize/heat the
papules so that they shrink over the subsequent few weeks. Though the PDL
has been used, the CO2 laser shows superior cosmetic results.
b. Neurobromas
As this condition has a dermal component, the CO2 is preferred.

1. UltraPulse laser, 13 mm spots with pulse energies ranging from 200 to
500 mJ, can be used.
2. After reaching dermis, the tumor, which has a rubbery consistency, can
be manually expelled by gentle pressure around the wound.
3. This is followed by additional passes of the laser to destroy the base.
4. Another approach is by using the cutting mode (0.2 mm spot) to excise
the stalks of the pedunculated lesions.
c. Pearly Penile Papules

An ablative pulsed or repeat mode CO2 is a very useful technique as it can
help minimize the bleeding.
Ablative Lasers 73
A setting of 13 W, 0.250.5 s exposures in the repeat mode or a 5 W, 0.1 s

burst is a useful method of achieving satisfactory results.
d. Syringoma
Surgical planend point is the ablation of syringoma to a depth just beneath
the surrounding uninvolved skin surface. A conservative end point is
removing about half to two-thirds of the lesion. This results in a depression
the skin that heals with minimal hypopigmentation and scarring.
1. Demarcate the syringoma with a surgical marking pen.
2. Infiltration anesthesia is required.
3. Place normal saline or sterile water soaked sponges and drapes around
the treatment area. This is primarily as the ablative lasers are absorbed
by water and this can minimize damage to the surrounding skin in case
of inadvertent laser impaction.
4. Either the Er:YAG or CO2 can be used.
CO2 power 15 W, (repeat continuous, pulsed or scanned beam at
0.10.2s), spot size (defocused beam with spot size of 23 mm at skin
surface). The spot size may be adjusted manually with the diameter of
the lesion.Er:YAG : 5 J/cm2, two or three passes.
5. Vaporizationdirect the shuttered beam to the lesion with one or two
pulses. Debride the treated area with a normal saline or sterile water
soaked sponge. Repeat vaporization and debridement, as necessary to
reach desired end point.
Pearls/Pitfalls
1. Hypopigmentation is a inevitable though reversible sequelae and the
patient should be forewarned about it (see Atlas).
2. Patients with infraorbital pigmentation should not be treated as the
pigmentary consequences are disastrous.
3. Always do a test site with one or two lesions prior to treating an entire
area.
e. Seborrheic Keratoses
Again the Er:YAG is superior to the CO2 laser as its has a minimal thermal
damage and almost perfect epidermal ablation (Fig. 2.19).
Settings
Er:YAG (25 J/cm2): End point is epidermal ablation. A whitish hue is
achieved by a single pass, this can be wiped off till a faint erythema appears
which indicates the papillary dermis
Figs 2.19A and B: (A) Seborrheic keratosis on the face. Plan to treat with Er:YAG;
(B) Postoperative view after 7 days, note the clean surface with little sign of PIH
CO2: Either a single spot Cw or UltraPulse modes can be used.

Care should be taken near the base of the lesion so that unnecessary heating
and subsequent pigmentation changes and scarring do not occur. This almost
never occurs with the Er:YAG laser, which is a reason for our preference for
using this system
f. Sebaceous Hyperplasia
This is one of the most rewarding and easy tumors to treat. It is our opinion
that for these the Er:YAG is an excellent tool and we prefer it over CO2 laser.
Settings: Er:YAG (23 mm spot; 45 J/cm2). CO2 (1 mm handpiece; pulse
energy of 200 mJ), the distance between the skin and handpiece tip is varied
to accommodate the size of the lesion.

1. A few overlapping passes are made to expose the yellow fatty nodules.
2. Once exposed, these punctate 0.5 mm lobules are treated with additional
pulses until they are either extruded are heated.
3. The nal result is a slight depression that resolves in 13 months.
g. Steatocystomas
The principle is to treat the lining of the cysts otherwise rapid recurrence is
the rule.
Ablative Lasers 75

1. First pierce the central portion with the 1 mm spot in the pulsed mode
(Repeat pulse).
2. Apply gentle pressure to the lesion to extrude the contents.
3. Apply a defocused laser passes to the lining.
4. Another alternative if the lesion are small is to vaporize the lesions with
subsequent passes.
5. The wounds are allowed to heal by secondary intention.
h. Trichoepitheliomas
Er:YAG and Cw and UltraPulse lasers have been used to treat these lesions.
End point: A ablation to a level just below the adjacent skin surface should
be the goal. Deeper ablation results in scarring and more supercial ablation
results in early recurrence.
Settings: The typical laser settings in Cw mode include 13 mm spot sizes and
powers of 25 W. If a UltraPulse mode is used, 200250 mJ energy is used. It
is our experience that a modulated Er:YAG can achieve excellent results with
minimal thermal damage
i. Xanthelasma
This common condition has been treated by multiple modalities including
surgery, TCA and lasers. Clinically the flat, papular, plaque and nodular
variants have been described. The importance being that for the last two
variants the depth of infiltration makes them unresponsive to most methods
except surgery.
1. Surgery: There are various techniques that can be used but inspite of
them recurrences are commonly seen. Moreover, it is impractical to
employ surgical means for recurrences, which are seen in the deeper
variants. We recommend surgery for a few, large lesions (plaques/
nodular) with a appreciable depth.
2. TCA: There are two important principles that determine the use of TCA.
First the concentration that should be used should be at least 30-70%
and secondly it is to be used in small lesions, with little depth. Moreover
a minimum of 3-5 sessions are required for most lesions
3. Laser: Though various lasers have been used, the ablative lasers are
superior to Nd:YAG, PDL, ruby and fractional lasers. Both CO2 and
Er:YAG can be used though the latter has a problem with the lack of
coagulation that leads to a decrease in the achievable depth and that
may lead to recurrences. As shown in the Figure 2.20 coagulative
effect of CO2 is ideal though in deeper lesions a residual lesion can still
remain.
Fig. 2.20: A figurative depiction of the effect of CO2 laser in xanthelasma. Note that for
a deep laser, recurrence can occur even though there is a coagulative component of
the pulsed CO2 laser
Step by Step Approach (Fig. 2.21)

1. Our approach is to use the 12 mm handpiece with either the UltraPulse
or Er:YAG laser.
2. A defocussed beam is used to initially ablate the epidermis.
3. This reveals the fat tissue. As the normal dermis is replaced by the fat
tissue the normal signs that determine the depth are not readily visible.
4. With the Er:YAG it is a good trick to ablate the surrounding epidermis
to give an idea about the depth achieved.
5. After ablating the epidermis, about 13 passes using a fluence of 10 J/cm2
with the Er:YAG is enough. Even if visible tissue remains the procedure
should be stopped. With the CO2 (5 J/cm2) again 3 passes are enough
to cause sufficient ablation of the fat tissue. The residual invisible
coagulation that extends deeper than the ablation is sufficient to help in
the ultimate removal of the lesion.
Pearls/Pitfalls
Even when some fat tissue is visible grossly, the coagulation and brosis
helps to remove the lesion. Excessive treatment can lead to complications,
thus it is better to undertreat than to overtreat.
Ablative Lasers 77
Figs 2.21A to C: (A) A case of xanthelasma, plan to treat with a Er:YAG laser; (B) Two
passes at 8 J/cm2. Note the clean ablation of epidermis with visible fat deposition;
(C) Two more passes are given with a slight perilesional extension which gives a
reliable end point (Glistening appearance of the papillary dermis)
After healing, at the next visit the residual lesion should be treated by
TCA and not by the laser as the tissue depth required may be less and lead to
overtreatment.
Our approach is to use the laser as a tool for both small and large lesions.
For the former a single session suffices while for the latter lesion, after the
initial session TCA can be used for residual lesions. If that fails surgical
excision is the only option. (Flow chart 2.1). A surgeon, though may adopt a
different approach.
Level of Difficulty
Variable.
7. Warts
Lasers Used
Development of human papilloma virus induced verrucae is a common
cutaneous disease process. The use of continuous wave or pulsed lasers has

Flow chart 2.1: A flow chart for management of xanthelasma with various modalities
been shown to have a efficacy in the range of 5681%. The use of ablative
lasers is only for warts that have been refractory to less invasive and less
costly measures. It has been noted that 80% of primary warts responded to
laser therapy, whereas only 48% of refractory lesions responded. Warts that
are particularly difficult to eradicate include those occurring in a periungual
area.
The Er:YAG laser has also been used successfully and has a better safety
profile. Most likely, the laser, like other destructive techniques, reduces the
viral load and allows for innate immunity to control the remainder wart
tissue. This should be the guiding principle of therapy with lasers.
Step by Step Approach (Plantar Wart)

1. Surgical planend point is the ablation of the plantar wart and 510
mm of surrounding uninvolved epidermis.
2. Treatment margins are outlined with a surgical marking pen.
3. Manually remove thickened hyperkeratotic debris. This tissue has low
water content and tends to act as a heat sink with laser impact, creating
excessive thermal diffusion.
4. Anesthesialocal inltration of 1% lidocaine with epinephrine into the
treatment area. Regional block may also be useful.
5. Use normal saline or sterile water soaked sponges and drapes around
treatment area.
6. Set laser parameterspower output 1525 W, waveform (continuous
wave, pulsed or scanned), spot size (defocused beam with spot size of
35 mm at skin surface).
Ablative Lasers 79
7. Vaporizationmove hand piece with air brush-like movements over

wart and surrounding epidermis to margins. Sweep the laser over the
verrucae 13 times. A cleavage plan at the dermoepidermal junction
will be created allowing the keratotic epidermis to be curetted away.
Vaporize any apparent wart tissue remaining. Coagulate the papillary
dermis to seal blood vessels.
8. Remove large pieces of desiccated wart from surface. Wipe treated area
with a normal saline or sterile water soaked sponge then blot with dry
sponge.
9. Repeat vaporization and debridement as necessary until normal dermis
is identied.
10. A 2 mm area around the wart should also be removed.
Dressingbactroban ointment/fucidin which is covered by a sterile
nonadherent dressing. We prefer using a Dynaplast instead of a routine
bandage.
Step by Step Approach (Common Wart)

1. If a wart is very exophytic, a higher energy of 1520 W and a 2 mm spot
size is used in the vaporization mode to ablate the surface of the lesion.
2. Residual debris is wiped away with moist gauze.
3. A curet can be used to separate the denatured tissue from the dermis. If
the heating plane at the dermal-epidermal (DE) junction is sufcient,
the wart will separate without much difculty and the underlying dermal
base will be only slightly heated. If one under treats, the unheated
remaining epidermis will still be attached to and interdigitated with the
underlying dermis.
4. Once the denatured wart is separated, the base is heated gently with a
lower power of 35 W. A rim 25 mm from the clinically obvious wart
should be heated. The underlying dermis can be identied by the
appearance of skin lines or the observation of slight tissue shrinkage.
Step by Step Approach (Periungual Wart)

1. A tourniquet greatly aids in hemostasis.
2. An aggressive therapy is required with curettage.
3. As the hard wart tissue in the nailfold can be mistaken for the normal
dermis a simple measure is to remove the surface till a smooth surface is
achieved.
4. If focal fatty globules are visible stop the treatment.
Step by Step Approach (Condylomata Acuminata)

1. Patients with perianal lesions may benefit from anoscopic examination
to evaluate for the presence of internal lesions.
2. Consider acetowhitening to help delineate subtle lesions.

3. Insert a moistened gauze into the anal sphincter or urethral orifice.
4. Used a pulsed laser or Er:YAG to treat the lesion until ablation (Fig.2.22).
5. Wound care: re-epitheliazation takes 34 weeks.
a.
Sitz baths with saltwater solution should be performed three or four
times daily
b.
Use a hair dryer instead of wiping
c.
Consider the use of stool softeners
d.
Refrain from sexual intercourse, douching or the application of
topical creams.
Pitfalls/Pearls
As most recurrences develop at the peripheral margin of a treated wart, laser
ablation should incorporate a zone of 35 mm of clinically normal appearing
tissue around the verruca.
Wart tissue bubbles upon treatment whereas normal epidermis exhibits
dermatoglyphics that appear to contract with laser contact. Thus a useful end
point is contraction of tissue which indicates adequqte ablation of the wart
For periungual warts, vaporization of the nail plate to gain access to
subungual extension of verrucae is not only helpful, but it eliminates the
need for nail plate avulsion
When treating virally mediated diseases with ablation, special safety
considerations are warranted. Viable viral particles have been demonstrated
in the smoke plume generated from the treatment of verrucae. Plantar warts
(HPV type 1) are the richest in viral particles.Because HPV 6 and 11 cause
both respiratory papillomatosis and genital warts, a major risk of inhalational
HPV infection exists when treating condyloma accuminata. Although viral
Figs 2.22A and B: (A) An intraurethral wart. The location dictated the use of a Er:YAG
laser as the CO2 can cause marked thermal damage and lead to a stricture; (B) A
modulated Er:YAG was used to ablate and coagulate the vessels
Ablative Lasers 81
transmission to the laser surgeon has not been convincingly demonstrated,

personal safety precautions are recommended. Intact and viable HIV
particles have been identified in CO2 laser plumes when HIV-infected tissue
was treated. No transmission of HIV through laser plumes has been reported
to date. Because of these factors, high efficacy smoke evacuators have to be
employed and the evacuation tube opening should be within 1 cm of the laser
plume. All personnel should don high-filtration laser masks with a particle
filtration threshold of 0.1 micrometer.
8. Excisional Surgery/Debridement
Excisions performed on infected issue may best be performed using a CO2
laser as the heat that is generated sterilizes the surgical field. Debridement
of decubitus ulcers, exuberant granulation tissue, and various cutaneous
infections such as botryomycosis and cutaneous leishmaniasis as well as
ablation of dermatophyte-infected nails have been effectively carried out
with a CO2 laser. Treatment of hidradenitis suppurativa, acne keloidalis
nuchae, and dissecting folliculitis of the scalp have also been reported. In
case of HaileyHailey disease as the depth to be achieved is less we feel that
the erbium:YAG laser is the ideal ablative lasers.
a. Nail Matrixectomy
Ingrowing Toe Nail
Ingrowing nail is classified in three stages. Stage 1 is characterized by
erythema, slight edema and pain on pressure. In stage 2, the symptoms
increase with local infection and discharge. In stage 3, granulation tissue and
lateral wall hypertrophy are seen.
Anesthesia
Proximal or distal digital block.
Tools
Tourniquet
Nail avulsion tray
Curette 3 mm.
Step by Step Approach (Fig. 2.23)

1. A tourniquet is placed to ensure a complete bloodless field.
2. The roof of the PNF is retracted with a hook or a thread allowing the lateral
matrix horn to be vaporized with the CO2 laser. Usually, a continuous
wave mode with about 4 W and a spot size of 1 mm is used; however, this
may be varied according to personal experience and the machine used.
Figs 2.23A to D: Steps of surgery (A) Nail block (proximal nail block); (B) Application
of tourniquet; (C) Lateral excision of nail and nail fold up to the matrix; (D) Immediate
postoperative; note the complete absence of bleeding (CO2 laser, Cw TW, 1 mm spot
size)
3. Extend the laser excision from the distal end to a point 5 mm medial to
a point at the intersection of proximal and lateral nail fold and a further
1cm proximally.
4. Then extend this further laterally as a wedge excision of the hypertro
phied soft tissue.
5. 12 passes are given on the edge of the incision.
6. This is followed by visualization of the cavity. If a white glistening fibers
are seen they indicate the matrix and this should again be ablated.
Pearls/Pitfalls
Some authors prefer to open the PNF over the lateral matrix horn to see more
clearly the extension of laser vaporization.
The speed and the excellent hemostasis are unique advanategs of the CO2
laser which is used in preference to the Er:YAG laser.
The most important advantage of the CO2 laser is that the coagulation
zone tends to take care of the remnant matrix tissue.
Ablative Lasers 83
Bibliography
1. Farley-Sakevich T, Grady JF, Zager E, Axe TM. Onychoplasty with carbon dioxide
laser matrixectomy for treatment of ingrown toenails. J Am Podiatr Med Assoc.
2005;95(2):175-9.
2. Karpen M. The CO2 laser used for matrixectomy. J Clin Laser Med Surg.
1992;10(6):454-6. PubMed PMID: 10148215.
b. Keloids
Earlobe Keloids
Earlobe keloids are particularly well suited to treatment with the CO2 laser. As
long as most of the keloid is vaporized and care is taken in the postoperative
period, a low rate of recurrence and a high degree of patient satisfaction can
be achieved.

1. A 3 mm handpiece with the UltraPulse laser with maximum pulse energy
and a high repetition rate of 2040 Hz, is used, the Cw CO2 with a settings
of 56 J/cm2, 0.09 sec can also be used.
2. Vaporize the lesion down to a point where one feels and sees very little
keloid at the base. This require many passes.
3. Use the thumb to push the keloidal tissue toward the laser handpiece.
After many passes, one will begin to feel mild heating on the nger as the
keloidal tissue is vaporized.
Pearls/Pitfalls
1. The pulsed mode allows for a relatively char-free tissue removal.
2. Even though a substantial amount of tissue may be removed, the contour
of the lower earlobe is unaffected.
3. Combination with interferons, imiquimod and IL steroid can also be
used.
Larger Keloids and Nonearlobe Keloids

The evidence does not favor the use of laser for other keloids and the CO2
laser probably offers little advantage over excisional surgery of keloids.
c. Hair Transplants
In hair transplantation, Er:YAG lasers may be used to drill holes for recipient
sites. Even in scarring alopecia, modern Er:YAG lasers with high pulse energy
can drill holes for hair transplants efciently, with less bleeding than with
punches, and with less tissue damage as with CO2 lasers, which is important
for graft up take.
9. Pyogenic Granuloma
These lesions respond very well to CO2 laser vaporization, provided that the
level of destruction is adequate. This includes cases that have recurred after
electrodesiccation and curettage (ED&C) and cryotherapy. This is probably
as the coagulative capacity of the CO2 laser helps to effectively seal the vessels
Step By Step Approach (Fig. 2.24)

1. The lesion is vaporized with 35 W power and a 24 mm spot size.
2. End point is to make the lesion ush with the surrounding skin.
3. This is followed by removal of the denatured friable surface.
4. Use a dermaview to visualize the central feeder vessel which is
surrounded by dermis or brofatty tissue.
5. Change the spot size of the laser and vaporize the bleeder using a
defocused beam with a long pulse duration.
Pearls/Pitfalls
A postoperative application of TCA 90% with an adhesive dressing like
Dynaplast helps in healing of the lesion.
10. Lymphangioma Circumscriptum

As CO2 has a ability to seal lymphatics this is the ideal laser to treat lymphatic
tumors. The ideal end point is lack of visible lymphatic drainage. Mild
hypertrophic scarring can occur (See Atlas). Because of the deep nature of
the lesions, lesions usually recur regardless of the treatment modality.
11. Vitiligo Surgery

Er:YAG has also been used for vitiligo surgery for preparation of the lesional
site for autologous melanocyte transfer, though not all believe it adds
substantially to the ultimate clinical results (Fig. 2.25).
Figs 2.24A and B: (A) Pyogenic granuloma on the medial border of the hand. Plan to
treat with a Cw CO2 laser; (B) Healing after 3 weeks with a scar, which is consequent to
the thermal damage induced by the CO2 laser
Ablative Lasers 85
Figs 2.25A and B: (A) A vitiligo patch prepared with Er:YAG (5 J/cm2); (B) End point
is mild bleeding, indicating the papillary dermis which is the desired end point
(Dr Sumit Gupta)
The Er:YAG laser with its exact ablation and no residual thermal damage
is ideal for preparing transplantation beds in bizarre and geometrically
complicated lesions and sites, like the nose, lips, ear and folds of skin.
12. Miscellaneous Conditions

Various lesions in difficult surgical locations may be addressed advantageously
using ablative lasers. A number of inflammatory conditions have been
reported to respond to ablation with the CO2 laser. The experience with
treating these conditions is limited to small numbers and large scale clinical
trial data are not available.
Some of these conditions include balanitis xerotica obliterans, Zoons
balanitis, kraurosis vulvae, lichen sclerosis et atrophicus, porokeratosis,
keratoderma, chondrodermatitis nodularis helices, granuloma faciale, genital
lichen planus, oral florid papiliomatosis, psoriasis, and lupus erythematosus.
STEP BY STEP APPROACH

CO2 LASER
Preoperative Considerations
Ideal Patient: The ideal patient for treatment, regardless of disease, is either
very dark or very light skinned, as patients tend to return to their constitutive
color after CO2 laser surgery.
Bronzed patients with Type II and III skin are at high risk for permanent
hypopigmentation with increasing depth of injury.
Any patient with decreased adnexal structures from previous radiation
therapy or even laser hair removal or electrolysis should probably receive at
least a test site. This advice is controversial for laser hair reduction, as there
are no reports of compromised healing in CO2 laser induced areas previously
treated with hair reduction lasers.
The recommended minimum time interval between isotretinoin
treatment and resurfacing (and vice versa) ranges from 6 months to 2 years.
Preoperative Regimen
For adnexal tumors, test sites, and small-scar abrasions, no systemic or
topical medications are prescribed. We have found that topical retinoids and
bleaching preparations do not appear to alter the postoperative course.
Intraoperative
Technique
Defocussed mode is ideal for vaporization while focused mode is used for
cutting. For most dermatological indications a pulsed laser is ideal. For
patients where a deeper ablation is required a superpulsed mode or a Cw
(interrupted pulse) can be used. Prolonging the pulse duration in a super
pulsed mode is another method of increasing the energy.
1. Modes (shuttered continuous wave, pulsed or scanned beam at 0.10.2
s): Most CO2 lasers have Cw (continuous wave), repeat, single, Sp (super
Pulse) and Up (ultraPulse) modes. The repeat and single are basically
CW modes.
As a thumb rule for small, appendageal tumours (e.g. milia) the single
pulse mode is ideal. For a larger lesion (xanthelasma), the repeat mode
in appropriate settings (see below) should be used.
2. Spot size (defocused beam) with spot size of 23 mm at skin surface.
3. The power density may be varied by changing the power output, beam
conguration, spot size, movement speed of hand piece, or shuttering
the laser beam. These changes may be done either by hand or with the
Ablative Lasers 87
use of a mechanical scanning device (details are given in the preceding

chapters).
Steps
1. After setting the power (at least 5 J/cm2) one pass is given.

Method: Air brush-like movements with the defocused laser beam of the
continuous wave carbon dioxide laser or discrete pulses of the pulsed or
rapidly scanned carbon dioxide laser create visible vaporization and/or
coagulation.
2. The surgeon should rely on visual inspection of the treatment site after
each pass of the laser and wiping the site with wet and dry sponges
in order to determine the extent of the lesion and surrounding tissue
damage.
First Pass: Vaporization of skin results in a white and slightly scaly
surface. Once the treated area is gently wiped with a wet sponge, the
epidermis may still be visible if the treated lesion is particularly thick
or the power density was very low and the speed of movement was very
fast. If the epidermis is thin and a greater power density is delivered, the
supercial dermis is seen with normal dermatoglyphic markings.
Dermis: When the dermis is heated or vaporized, visible collagen
contraction is noted. If coarse and woven collagen bundles are seen, the
tissue has been ablated into the deep dermis.
Subcutaneous: If ablation is continued further, subcutaneous fat will be
obvious.
If charring is seen, there has been slow tissue burning at very high
temperatures resulting in heat diffusion to surrounding tissues rather
than tissue ablation. Charring is therefore not desired.
Postoperative Care
1. With the exception of excised wounds, in which sutures should be left
in 35 days longer than in scalpel wounds, wounds are left to heal by
secondary intention and will heal optimally when kept moist and clean.
Dressings will speed healing if they are changed (at least every 2 days).
2. We have used a combination of fucidin cream (less sensitizing than
neomycin) with application of aloe vera gel (Jula or Aloekem 75) till the
crusting falls off. We routinely recommend an antibiotic, starting one
day prior to 4 days after the surgery (Levofloxacin 750 mg HS) with an
antinflammatory drug for two days (Zymoflam-D).
3. To avoid PIH a combination of sunscreen and non HQ/steroid based
creams is given. A physical block sunscreens is advisable.
4. More disturbing than the almost always temporary, especially on
the face, postinammatory hyperpigmentation, is the delayed onset
of hypopigmentation after the CO2 laser in some cases. Thus as far as
possible Cw CO2 should be restricted to small areas of the face.
Pitfalls/Pearls
1. Optimal use of the carbon dioxide as an ablative instrument includes
many steps.
2. The most important is to determine the desired clinical end point which
varies depending on the lesion treated.
Actinic cheilitis: End point is coagulation or white discoloration of the
entire external lower mucosal lip is seen.
Epidermal Nevus: Evidence of some coagulation in the dermis under
the ablated area.
Plantar Wart: The presence of normal dermis under the visible wart as
well as 510 mm surrounding it.
Appendageal Tumors: The clinical end point for the treatment of small
appendageal tumors of the face includes vaporization of epidermis and
dermis to a depth just beneath the surrounding uninvolved skin.
ERBIUM:YAG
Though most of the aspects mentioned under CO2 laser surgery are common
some unique aspects apply to the Er:YAG laser.
1. Wherever full face resurfacing is needed modulated Er:YAG is superior
to CO2 laser.
2. Although the supercial ablation and minimal collateral thermal
damage achieved with the Er:YAG laser allow physicians to treat patients
with more condence, careful patient selection is still essential.
3. For most dermatological indications except vascular and lymphatic
disorders Er:YAG is the ideal laser.
Patient Selection
Absolute contraindications to laser resurfacing include active bacterial or
viral infections, impaired immune system, use of isotretinoin in the past year,
and history of poor healing, especially hypertrophic scars or keloids in the
treatment area. Skin that has received extensive radiation therapy or patients
with scleroderma show decreased amounts of adnexal structures and should
not be resurfaced because of risks of poor healing. Patients with unrealistic
expectations should not be resurfaced.
Pregnant patients are also not treated due to the unknown risk of
anesthesia on the fetus.
Relative contraindications include history of prior skin dyspigmentation,
skin types V and VI, and koebnerizing diseases such as vitiligo or labile
psoriasis. Patients who had a prior blepharoplasty or who have signicant
eyelid laxity should be approached cautiously, since the tightening achieved
during laser resurfacing may result in ectropion formation.
Ablative Lasers 89
Pretreatment Regimen
All patients undergoing laser resurfacing of the face are typically
prophylactically given either acyclovir 400 mg PO tds, valacyclovir 500 mg PO
bid, or famcyclovir 250 mg PO bid. The antiviral is started 2 days prior to the
procedure and continued for 10 days after the procedure. We though do not
follow this as a rule and if there is no elicitable history of herpes labialis there
is no need to administer antivirals.
Prophylactic use of systemic antibiotics, such as dicloxacillin, cephalexin,
or azithromycin in penicillin allergic patients, should be given 2 days prior
and continuing until the skin has re-epithelialized, to diminish the incidence
of postoperative infection. We prefer levofloxacin 750 mg HS.
A moist, warm wound environment also promotes candidal infections.
Occasionally,a single dose of uconazole may be given on the day of surgery
to patients, especially those with a signicant history of recurrent vaginal
discharge.
Intraoperative
Anesthesia: Infiltration anesthesia
Treatment Technique
The basics have been described in the text and today resurfacing is not the
primary indication. For almost all ablative indications except vascular and
lymphatic, Er:YAG is better than CO2 laser. This is specially true of the new
variable pulse lasers where the pulse duration can be increased to match the
coagulative effects of CO2 laser.
Method
1. Er:YAG resurfacing can be performed either freehand or with a scanner.
If the freehand method is used, it is important to ensure that overlapping
of pulses is moderate, but not great. Signicant overlapping and stacking
of pulses will increase the depth of ablation and collateral thermal
damage.
2. The number of passes necessary to vaporize the epidermis depends on
the uence and spot size used. In general, a uence of 57 J/cm 2 will
ablate the epidermis in two to four passes and a uence of 815 J/cm 2
will do so in one or two passes. Subsequent passes will ablate between
5 and 40 mm of tissue depending on the energy uence used. This is
based on a rough estimation of an ablation of 5m of the skin per J/cm2
of energy.
3. To minimize thermal damage subsequent passes should be oriented
perpendicular or at an angle to the preceding passes to further enhance
the uniformity of the ablation.
4. The margins of the treatment areas can be blended into the untreated
skin by using pulses of lower uence or by defocusing the handpiece or
scanner (which, in effect decreases the uence).
5. A quick wipe between passes with moistened gauze is recommended to
remove the ne tissue debris, to rehydrate the skin, and to allow better
visualization of the plane being treated. This process only takes a few
seconds and does not require the time and effort associated with wiping
between CO2 passes.
Dose/Depth
With a of 5 J/cm2, the following ablation depths are usually achieved: one
pass, 2040 m or down to the granular layer of the epidermis; two passes,
up to 60 m or down to the basal cell layer; three to four passes, 80120 m
or down to the papillary dermis, and deeper into the papillary and supercial
reticular dermis after ve to six passes (Alster, Perez).
Weinstein (1997) described the following ablation depths using a scanner
of 20 Hz and 30% pulse overlap: 5 J/cm2, supercial epidermal injury (3040
m) with negligible thermal necrosis; 10 J/cm2, epidermal injury to the level
of the basal layer (50 m) with minimal thermal necrosis (5 mm); 15 J/cm2,
full-thickness epidermal injury through the basement membrane, minimal
ablation of the papillary dermis (20 m), and a narrow band of thermal
necrosis (1015 m). These schematic histological ablation depths provide an
approximation of the real ablation depth achievable with different uences
and numbers of passes.
End Point
The visual endpoint for treatment with the Er:YAG laser differs from that of
the CO2 laser. The chamois yellow color seen with CO2 resurfacing, which
indicates that the deep papillary dermis or supercial reticular dermis is
reached, is not seen with Er:YAG laser resurfacing.
Epidermis: Resurfacing within the epidermis produces a yellowish brown
appearance on the epidermis.
Epidermo-dermal junction: Once the epidermis is removed, a pinkish
appearance of the upper papillary dermis will be readily appreciated. The
follicle openings look small and regular like a ne sponge.
Lower papillary dermis: When proceeding in to the papillary dermis,
pinpoint bleeding and a transudate develops, indicating injury to the small
capillaries. The follicle openings become wider and begin to stand out from
the surrounding dermis.
Upper reticular dermis: When the upper reticular dermis is reached,
bleeding increases and the transudate becomes more profuse. Follicle
openings become much wider and the collagen bands become coarser and
Ablative Lasers 91
more haphazard in orientation. At this point it is generally best not to proceed

no further.
Therefore, the physician must be mindful of the estimated depth of
ablation associated with each pass of the laser at the uence being used,
and compare that with the average depth of the epidermis and dermis of the
area being treated. As the collateral thermal injury induced by the Er:YAG
laser is insufcient to coagulate medium-sized vessels, a common visual clue
indicating that ablation has reached the mid-dermis is pinpoint bleeding.
This bleeding will often inhibit further treatment beyond a certain level.
Thus if the rhytides, acne scars, or other lesions are adequately effaced
before the bleeding and exudate limit further treatment, then one or two
additional passes are done to compensate for the impact edema. If oozing is
remarkable, gauze soaked with 1% lidocaine with epinephrine can be placed
over the resurfaced area at the end of the procedure.
Postoperative Care
For small lesions, we recommend topical antibiotic ointments or ointments
specically designed to accelerate wound healing (e.g., Fucidin). This should
be used until complete re-epithelialization has occurred and prevents the
formation of irritating crusts.
For extensive lesions as in skin resurfacing, either the open technique
(application of ointments several times a day, following irrigation with water
or vinegar solutions) or the closed technique (application of various kinds of
occlusive dressings for several days) can be used.
Pearls/Pitfalls
To complement the effect of Er:YAG and CO2, a combination approach is a
useful concept. This helps to balance out the advantage of fine ablation of
Er:YAG and coagulation of CO2.
A often asked question is whether this may lead to accentuated thermal
damage. This has been answered by the histological examinations of Utley
et al., who found the following residual thermal damage zones after ablation
with an Er:YAG and a pulsed CO2 laser (at 4.7 J/cm2 each).
a. CO2 alone (four passes) 89 m, Er:YAG (four passes) and CO2 (two
passes) 97 m.
b. Er:YAG alone (eight passes) 43 m, and CO2 (two passes) and Er:YAG
(four passes) 56 m.
Thus a simple protocol is to combine Er:YAG initially followed by CO2 for
deep pathologies while Er:YAG suffices for most superficial indications.
This helps to maximise results by using the almost predictable ablation of
Er:YAG with coagulation of CO2 lasers.
BIBLIOGRAPHY
1. Alster TS. Clinical and histologic evaluation of six erbium:YAG lasers for
cutaneous resurfacing. Lasers Surg Med. 1999;24:87-92.
2. Hohenleutner U, Landthaler M. Er:YAG Lasers. Principles and practices in
cutaneous laser surgery/ed, Kauvar ANB; Associate ed, Hruza GJ. Taylor and
Francis; 2005.
3. Perez MI, Bank DE, Silvers D. Skin resurfacing of the face with the erbium:YAG
laser. Dermatol Surg. 1998;24:653-9.
4. Ross EV. Continuous Wave and Pulsed CO2 Lasers. Principles and practices in
cutaneous laser surgery/ed, Kauvar ANB; associate ed, Hruza GJ. 2005. Taylor
and Francis.
5. Tse Y, Manuskiatti W, Detwiler SP, Fitzpatrick RE, Goldman MP. Tissue effects of
the erbium:YAG laser with varying passes, energy and pulse overlap. Lasers Surg
Med. 1998;22(suppl 10):70.
6. Utley DS, Koch RJ, Egbert BM. Histologic analysis of the thermal effect on
epidermal and dermal structures following treatment with the superpulsed CO2
laser and the erbium:YAG laser: an in vivo study. Lasers Surg Med. 1999;24:93102.
7. Weinstein C. Computerized scanning erbium:YAG laser for skin resurfacing.
Dermatol Surg. 1998;24:83-9.
8. Weinstein C. Erbium laser resurfacing: current concepts. Plast Reconstr Surg
1999;103:602-16.
Ablative Lasers 93
ATLAS
Fig. 1: A case of epidermal nevus, a test spot is treated with Er:YAG (10 J/cm2; 4 Hz).
Note the healing with residual and transient pigmentary loss.
Fig. 2: A case of epidermal nevi, on the neck test spot treated with Er:YAG (10 J/cm2; 4 Hz)
Fig. 3: Intraoperative procedure using the paintbrush technique with the Up CO2
lasers (350 mJ; 5 J/cm2; <1ms). Note the almost bloodless field due to the coagulative
effect of the laser
Fig. 4: A compound acquired hairy melanocytic nevi
Ablative Lasers 95
Fig. 5: Immediate postoperative view using a Up CO2 lasers (350 mJ; 5 J/cm2; < 1ms).
Note the complete lack of bleeding. Concomitant thermal necrosis is visible as charred
tissue on the periphery
Fig. 6: Immediate postoperative photograph of a melanocytic nevus using the Er:YAG

(10 J/cm2; 4 Hz). Note the capillary bleeding seen at the level of papillary dermis. The
lack of coagulation is an useful tool to determine a reliable end point
Fig. 7: A preoperative photograph of lympho (hemangioma) circumscriptum
Fig. 8: Intraoperative use of CO2 (superpulsed mode; paintbrush technique) which is

the ideal laser for coagulation of lymphatic vessels
Ablative Lasers 97
Fig. 9: Healing with hypertrophy of the skin due to the concomitant thermal tissue
effect of the CO2 laser
Fig. 10: Multiple seborrhoeic keratosis on the face
Fig. 11: Single spot technique using Up CO2 (350 mJ; 5 J/cm2; < 1ms). End point is
mild crusting
Fig. 12: Syringoma are eccrine gland tumors. Ideal laser is Er:YAG due to its better
side effect profile in pigmented skin specially on the face
Ablative Lasers 99
Fig. 13: Post-treatment with Er:YAG (5 J/cm2; 2 Hz; single spot technique) healing
with pigmentary alteration, which is an inevitable but reversible sequelae
Fig. 14: A case of bilateral xanthelasma palpebrum. Plan (Er:YAG; 10 J/cm2; 4 Hz).
End point is ablation of the tumor
Fig. 15: Postoperative view after 4 months. Note the healing and the variable
response which depends on the on the depth of lesion
CHAPTER
Pigmented Lesions and Tattoos

Kabir Sardana, Rashmi Ranjan, Payal Chakravarty,
Khushbu Goel, Anuj Tenani, Anjali Madan
OVERVIEW
Laser-Tissue Interactions in Pigmented Skin
Selective photothermolysis was originally applied to the treatment of vascular
lesions with oxyhemoglobin as the target chromophore. Thereafter, selective
photothermolysis was applied to pigmented lesions by targeting endogenous
melanin and exogenous carbon particles as target chromophores.
As a target chromophore, melanin has a broad absorption spectrum
within the ultraviolet, visible and near-infrared light range (Fig. 3.1). Thus,
while most lasers can be used for treating pigmented disorders, the light
absorption in melanin decreases steadily with increasing wavelength. Also,
there are competing chromophores, thus the window of opportunity is
between the wavelengths of 6301100 nm where the melanin absorption
exceeds that of Hb. But as the absorption of melanin falls with a higher
wavelength, a higer fluence is needed.
The melanin containing melanosomes are 0.5 m in diameter and are
predicted to have a thermal relaxation time between 50 ns and 500 ns. Thus,
ideally Q-switched lasers would be effective in treating the disorders. With
increasing wavelengths, melanin absorption decreases but the required
threshold laser exposure dose increases. This is relevant (Fig. 3.1) as the lasers
that is used in India QS Nd:YAG (1,064 nm) would require a higher fluence
than the other lasers. This can lead to PIH, which is a decidedly common
feature. More importantly is the sequelae of hypopigmentation and thus the
authors do not recommend using this laser for melasma.
When treating pigmented lesions, Q-switched lasers generate an
immediate ash-white color at the site of impact (Fig. 3.2). The cause of this
tissue response is due to heat-induced steam cavities in melanosomes which
cause a scattering of visible light, producing a white color. The adequate
laser exposure dose for melanosome damage correlates well with the clinical
threshold for immediate skin whitening. In other words, if the clinical ashwhite color is not visible, the laser exposure dose is not sufficient. Darker
skin has a lower threshold for whitening due to a higher epidermal melanin
Abbreviation: OD, optical depth
Fig. 3.1: Absorption coefficient of melanin in relation to the common lasers used for
pigmented lesions
Fig. 3.2: A white end point is the ideal dose level for a Qsw Nd:YAG laser
Pigmented Lesions and Tattoos 103
content, thus a lower dosage than recommended for fairer skin types should
be used.
There are certain variables that determine the efficacy of lasers in
pigmented lesions.
Wavelengths
The various lasers used include the pulsed tunable dye laser (wavelength
435750 nm, pulsewidth 300750 ns), Q-switched ruby laser (wavelength
694 nm, pulse width 40 ns) and the Q-switched neodymium:YAG laser
(wavelength 355, 532 and 1,064 nm; pulse width 1012 ns). While shorter
wavelengths, such as 351 nm are better at absorbing melanin, longer
wavelengths penetrate deeper into the skin, increasing their ability to reach
deeper melanosomes (Fig. 3.3). This principle accounts for the use of Qsw
Nd:YAG 532/1064 nm in dermal disorders.
Lasers Used
The laser used vary, but in accordance with the principles of selective
photothermolyis, ideally pigment selective lasers should be used. Other
systems have also been used and are enumerated in Box 3.1.
The lasers used include: (1) Pigment nonselective, (2) Highly pigment
selective, (Qsw Lasers) (3) Pigment selective lasers (Box 3.1).
Fig. 3.3: Common lasers used for pigmented lesions with their penetration depth
Laser type
QS FD Nd:YAG
QS Alexandrite
QS Nd:YAG
QS
alexandrite
QS Ruby
QS FD Nd:YAG
QS Nd:YAG
QS Nd:YAG
QS FD Nd:YAG
QS Nd:YAG
QS Ruby
Q-switched Nd:YAG
laser
Q-switched ruby
laser
Fractional ruby
FD Nd:YAG
Device
(manufacturer)
Alex
TriVantage
(Candela)
AlexLAZR
(Candela)
EpiTouch
(Lumenis)
Medlite C6
HOYA
(ConBio)
ProTMQ-1064/532
(Protocadmus)
SkinClear
(Sybaritic)
Spectrum
RD-1200
(Palomar)
Tattoo Star
Q-switched laser
(Ascepelion)
Versa Pulse
VPC
(Lumenis)
250 ms
40 ns
694
532
8 ns
28 ns
10 ns
10 ns
6 ns
520 ns
25 ns
50 ns
50 ns
Pulse
duration
1,064 and 532
694
532
1,064
1,064
532
532
1,064
694
755
532
755
1,064
Wavelength
(nm)
Box 3.1 A summary of the various lasers used for pigmented conditions
210
24.5
5, 6.5
1, 2, 3
1, 2, 3
14
2, 3, 4, 6
3, 4, 6, 8
2, 3, 4
2, 3, 5
2, 3, 4
Spot size
(mm)
10
0.8
25
10
0.8
5
5
Hz
Four lasers within one
First fractional, Qsw ruby laser
Large spot size promotes deeper penetration
Handpiece converts wavelength to 585 nm and

650 nm
Long pulse mode available for hair removal
Fiberoptic delivery system
Comments
Pigment nonselective lasers: The carbon dioxide (10,600 nm), Erbium-YAG

(2,940 nm) and the yttrium scandium-gallium-garnet (YSGG) (2,790 nm)
lasers are pigment nonselective lasers that remove epidermal pigment
because of their ability to target water and ablate the entire epidermis,
including melanocytes and melanized keratinocytes. They are useful only if
used in a dose settings within the thermal relaxation time of the skin (<1 ms).
If it is beyond that thermal damage will ensue which will lead to more side
effects.
The fractionated CO2 and fractionated Erbium:YAG lasers work in the
same manner as their non- fractionated counterparts but deliver the light in
many small columns. Because only fractions of the pigmented epidermis are
affected, a series of treatments is necessary to achieve the desired result and
at least some of the original pigmented epidermal lesion would remain even
after a series of treatments resulting in incomplete lesion removal. We are
not proponents of using this technology except the fractional Qsw versions
(Tattoo star Fr:QS Ruby) for pigmented lesions (Box 3.1).
Highly pigment selective lasers: There are three short-pulsed, pigment
selective lasers that are widely used today: (1) The Q-switched ruby laser
(QSRL) (694 nm), (2) the Q-switched alexandrite laser (755 nm), and (3) the
Q-switched neodymium:YAG (Nd:YAG and KTP) laser (1,064, 532 nm). These
lasers selectively target melanin by delivering high-intensity, short-pulsed
radiation at varying wavelengths (Fig.3.3).
The QSRL emits light at a wavelength of 694 nm and a pulse duration of
2840 ns.
The Q-switched alexandrite laser has a near infrared wavelength of
755nm, pulse duration of 50100 ns, spot size of 24 mm, and a repetition
rate up to 10 Hz.
The Q-switched Nd:YAG laser emits infrared light at 1,064 nm. The wavelength can be halved by placing a frequency-doubling KTP (potassiumtitanyl-phosphate) crystal in the laser beams path. Dye-impregnated
handpieces can convert the 532 nm wavelength to either 585 nm (yellow) or
650 nm (red). An articulated arm delivers pulses with a spot size to 1.58 mm,
a pulse duration of 510 ns, and a repetition rate up to 10 Hz.
The difference between non-FDA approved lasers and the FDA approved
devices is in the beam profile. Most lasers in this classes have a Gaussian beam
profile, thus requiring overlap and thus leading to more thermal damage.
In pigmented lesions, this can have a detrimental effect. This is depicted in
Figure 3.4.
Less pigment selective: The Q-switched ruby, alexandrite and Nd:YAG
lasers also have long-pulsed counterparts with the same wavelengths that
operate in a normal (non-Q-switched) mode. These normal mode lasers are
often used for laser hair removal because their higher fluences and longer
pulse durations target large pigmented structures such as hair follicles or
Fig. 3.4: A comparison of the beam profile of QS Laser (Asclepion Laser

Technologies, GmbH)
nests of cells rather than individual melanosomes or pigmented cells (Ueda

et al.). Normal mode lasers have been shown to be effective in the removal
of epidermal pigmented lesions but are not ideal because damage may be
imparted on surrounding tissue.
Long-pulsed (millisecond rather than nanosecond domain) 532 nm
(KTP) Nd:YAG lasers and 595 nm pulsed-dye lasers, which are traditionally
used to treat vascular lesions, can also be used to treat superficial pigmented
lesions. However, the long pulse width of these lasers is close to the thermal
relaxation time of the entire epidermis (about 10 ms) and therefore, does not
allow for selective damage to melanosomes.
Because of their longer pulse width, millisecond domain lasers produce
a purely thermal effect on their target, unlike the photomechanical effect of
Q-switched lasers. The target in this case may in fact be melanocytes rather
than melanosomes. Regardless, these longer pulse duration devices, just
like intense pulsed light devices are highly effective in removing unwanted
epidermal pigment. These lasers are not suitable for treating dermal
pigmented lesions because of the limited penetration depth (Kono et al.).
Indications
Pigment lasers can be used for various indications and are conveniently
divided in to epidermal and dermal disorders (Fig. 3.5). As a thumb rule, the
efficacy of lasers results is: epidermal > dermal > mixed. Another practical
method of classifying the conditions are static conditions (Nevocellular
nevus) and dynamic conditions like melasma, the latter of which have
inconsistent results.
Fig. 3.5: Summary of the salient conditions amenable to treatment by

pigmented lasers
Epidermal Pigmented Lesions

The common indications include: ephelides, lentigines, Caf au lait macules,
seborrheic keratoses, nevi spilus and Beckers nevi. Since pigment in
epidermal lesions is found superficially, shorter-wavelength devices can
be used successfully despite their limited penetration depth (Fig. 3.3). The
510 nm wavelength of the pigmented lesion pulsed dye laser and 532 nm
pulsed lasers are highly absorbed by melanin but penetrates to a depth
250mm into the skin (Anderson et al.). The Q-switched ruby and alexandrite
lasers effectively treat both epidermal and dermal pigmented lesions since
their wavelengths are still within the melanin absorption spectrum and they
penetrate deeply into the dermis. The Nd:YAG (1,064 nm) laser penetrates
deeply but is poorly absorbed by melanin, making the 532 nm wavelength
preferable for epidermal lesions. When using the 510 nm and 532 nm
wavelengths, hemoglobin competes with melanin for absorption of light.
Nanosecond pulses at these wavelengths causes rupture of superficial blood
vessels, which may manifest clinically as purpura.
Dermal Pigmented Lesions

The conditions amenable to treatment include: melanocytic nevi (acquired
and congenital), nevus of Ota, and melasma. The Q-switched ruby,
alexandrite and 1,064 nm Nd:YAG are the most commonly used lasers. All of
these lasers are still within the absorption spectrum of melanin yet also have
wavelengths that are long enough to penetrate into the dermis (Fig. 3.3). A list
of common disorders with the modes of treatment is listed below (Table 3.1)
while a detailed discourse will follow in the coming chapters.

Table 3.1
A summary of laser treatment for selected disorders
Condition
Laser
Results
Acquired melanocytic
nevi
(Moles)*
QS ruby laser (694 nm)

QS Alex (755 nm)
QS Nd:YAG (1,064 nm)
Normalmode ruby laser
(NMRL)
Long Pulse Alex
Er:YAG
Up CO2
Recurrence is a distinct
possibility
Lighter nevi respond best to
shorter wavelengths while
darker nevi typically respond
to any wavelength within the
melanin absorption spectrum
We prefer the Er:YAG/Up CO2
laser over the pigment specific
lasers
Beckers Nevus
Er:YAG lasers
QS 1,064 nm Nd:YAG
Long-pulse 755-nm Alex laser
Incomplete results with most

lasers
In resistant cases Er:YAG
ablation is an option
Caf au lait Patches
QS 694 nm ruby laser

QS 532 nm Nd:YAG
NMRL or LP Alex
Er:YAG
Inconsistent and incomplete

results
Long Pulse Alex has been
used as its tends to decrease
recurrence and the number of
sittings
The principle is that the longer
pulse allows for collateral
damage to non-pigment
containing melanocytes
Drug-induced
Pigmentation
Q-switched 532 nm/1,064 nm

Q-switched Alexandrite
Useful for minocycline

induced pigmentation
Freckles and
Lentigines
Almost all Qsw lasers can be

used. Ideal is QS-532 nm
Long pulse lasers have also been
tried
Easy to treat with consistent

results (13 sittings)
Infraorbital
hyperpigmentation
QS Ruby lasers
QS Alex lasers
Effective only in cases with

deposition of dermal melanin
Melasma
Resurfacing lasers
Fractional lasers
Fractional ruby
Pigment lasers/IPL
Q-switched lasers
Laser toning
(low-fluence, QS
1,064-nm Nd:YAG laser, setting
(68 mm spot size, 1.62.3 J/cm2)
Vascular lasers
In Indian skin, the results are

erratic and transient with all
lasers
Contd...
Contd...
Condition
Laser
Results
** Nevus of Ota
QS Nd:YAG-1064/532 nm
QS Alexandrite (Alex)-755 nm
The number of treatment

session varies and depends on
age, color and size of the lesion
A recent study gives a realistic
view of results based on the
color ** of the lesion (Felton
SJ et al.)
Nevus Spilus
QS ruby
QS Alex
QS 532 nm Nd:YAG laser
Combination of carbon
The darker nevocellular nevus

clears but the background
pigment persists
*Congenital nevus are difficult to treat and require a ablative laser in combination with a pigment
specific laser ** blue-colored lesions improved with all modalities, brown with QS Nd:YAG-532 nm/
QS Alex-755 nm, blue-gray with QS Alex-755 nm/QS Nd:YAG-1064 nm while gray lesions are the
most resistant. Type V skin were the most resistant to therapy (Felton SJ et al.)
TREATMENT APPROACH OF PIGMENTED LESIONS/TATTOO

Prerequisites
1. History of keloids, any bleeding diathesis, or history of infectious
diseases, particularly hepatitis and HIV infection.
2. Patients with a recent history of isotretinoin use should be treated with
caution.
3. A pretreatment biopsy should be performed if there is any possibility of
atypia in a pigmented lesion or if the diagnosis is at all in question.
4. Realistic Goals: The patients of Beckers nevi, CALM and Nevus spilus
should be forewarned about the possibility of incomplete results. For
tattoos, it can take 6 to 10 treatments or more to remove a tattoo and
sometimes a ghost image of the tattoo may remain.
Pretreatment Preparation
The main competing chromophore during tattoo treatment is melanin
pigment. The laser light has to traverse this to reach the tattoo. Thus a
bleaching agents such as alpha-hydroxy acid lotions combined with topical
corticosteroids and/or hydroquinone may be used (24 weeks). It is the
opinion of some authors (including us) that this does not markedly affect the
final results.
Steps of Therapy
1. Topical EMLA is sufficient in most cases. In case of pain infiltration,
anesthesia is an option.
2. Eye protection is a must and either eye shields or an eye cover should be
provided.
3. A hydrocolloid dressing can be applied, as pieces of skin can often
be aerosolized and blood can spatter during tattoo treatments with
Q-switched lasers (Fig. 3.6).
This is because the rapid heating of the skin surface during the
extremely short pulses delivered by Q-switching, causes a shock wave to
be generated (Fig. 3.7).
4. The laser handpiece should be held perpendicular to the skin with the
attached plastic cone or guide resting on the skin to ensure that the laser
beam is focused on the area to be treated. In some models, there is no
such guide, thus, the probe should be moved closer till the popping
sound is heard.
Dose/Method
In general, lower fluence is used for dark lesions that contain larger amounts
of absorbing chromophore.
One or two laser pulses should be fired at the lesion to ensure that a
threshold response occurs, which is defined as immediate whitening of the
lesion. The optimal tissue end point is uniform immediate whitening without
epidermal disruption (Fig. 3.8). The lowest fluence required to invoke this
response should be used. When the fluence is too low, the whitening will be
barely noticeable. If the fluence is too high, whitening is a confluent bright
white and epidermal damage with bleeding may occur. This may result in
Fig. 3.6: Hydrocolloid dressings are useful in cases of tattoos where higher fluences
are needed and tissue splattering occurs
Fig. 3.7: Intense photothermal effect of a 1,064 nm Nd:YAG in Qsw mode in a

case of tattoo
Fig. 3.8: Note the diffuse whitening due to the Qsw 532 nm in a case of nevus spilus
(2.5 J/cm2 Protocadamus)
tissue sloughing, prolonged healing and also a greater likelihood of postinflammatory hyperpigmentation or hypopigmentation or textural changes.
It is advisable specially in pigmented skin that a test spot be done before
deciding the final therapy regimen (Fig. 3.9).
Fig 3.9: A case of CALM, an initial test spot is given with the Qsw 1,064 nm for the
upper part and 532 nm for the lower part of the lesion. The postlaser healing will
dictate the ideal laser to be used (2.5 J/cm2 Protocadamus)
After the optimal fluence is determined, pulses can be delivered rapidly

(up to 10 Hz, depending on the laser). As far as possible, overlapping should
be avoided.
Subsequent Sittings
They are performed 6 weeks after the original treatment. An increment of
12J/cm2 can be done, if needed.
Number of Sittings
While some pigmented lesions (e.g, lentigines) may require only one to
two treatments, other lesions (e.g. Caf au lait macules) may need multiple
treatments.
An overview of treatment and guide to dosimetry is give in Appendix 1,
the details will be discussed in the coming chapters.
Postoperative Course
The white tissue reaction that occurs immediately after Q-switched laser
treatment fades within 20 min. An urticarial reaction, causing erythema,
edema, itching, and stinging, may develop in and around the treated area.
In all patients, the treated lesions appear darker for several days then
develop a thin crust that flakes off in 710 days. The risk of blistering is highest

Appendix 1 A summary of standard dosimetry for select disorders
Dermatoses
Wavelength
Diameter (mm)
Dose (initial)
Comments
Caf-au-Lait
Spot
532 nm
2 J/cm
Treatment not
successful
in every case
Freckles
532 nm
2 J/cm
The results are

temporary
with rapid
recurrence
Amateur Tattoo
1,064 nm
14
3.5 J/cm
On average 46
treatments
Professional
Tattoo,
very black
1,064 nm
14
3 J/cm2
On average
610, sometimes
up to 20
treatments
Professional
Tattoo,
red
532 nm
14
2 J/cm
On average
610, sometimes
up to 20
treatments
Dirt Tattoo
1,064 nm
14
3.5 J/cm
Dirt particles
can shoot
out
when shorter wavelength devices (e.g. QSRL) are used to treat patients with
dark skin phototypes. Following treatment with the Q-switched 532 nm
Nd:YAG, purpura usually develops after skin whitening has faded. This
occurs because these wavelengths are well absorbed by both melanin and
hemoglobin.
Patients should be instructed to gently wash the treated area with mild soap
and apply an occlusive ointment (e.g. petrolatum) twice a day. We routinely
advise a combination of aloe vera gel (40%) in the morning with fucidin
cream at night. Any crusting should be allowed to slough spontaneously.
To minimize the risk of hyperpigmentation and recurrence, patients should
avoid excessive sun exposure and use a broad-spectrum sunscreen of SPF 30
or higher for several months after treatment.
BOOKS
1. Goldberg, Dover JS, Alam M. Procedures in cosmetic dermatology series: Lasers
and Lights: part1/2; 2006.
2. Hruza GJ, Avram M. Lasers and Lights: Procedures in Cosmetic Dermatology
Series (Expert Consult - Online and Print), 3rd edn. October 2012.
3. Laser dermatology: Pearls and problems by Goldberg DJ 2011.
4. Lasers in dermatology and medicine. Nouri K (Ed); 2011.
BIBLIOGRAPHY
1. Anderson RR, Parrish JA. The optics of human skin. J Invest Dermatol. 1981;77:
13-9.
2. Felton SJ, Al-Niaimi F, Ferguson JE, Madan V. Our perspective of the treatment of
naevus of Ota with 1,064-, 755- and 532-nm wavelength lasers. Lasers in medical
science. May 2013.
3. Kono T, Manstein D, Chan HH. Q-switched ruby versus long-pulsed dye laser
delivered with compression for treatment of facial lentigines in Asians. Lasers
Surg Med. 2006;38(2):94-7.
4. Sardana K. The science, reality, and ethics of treating common acquired
melanocytic nevi (moles) with lasers. J Cutan Aesthet Surg. 2013 Jan;6(1):27-9.
5. Sardana K, Chugh S, Garg VK. Which therapy works for melasma in pigmented
skin: lasers, peels, or triple combination creams? Indian J Dermatol Venereol
Leprol. 2013;79(3):420-2.
6. Sardana K, Chugh S, Garg V. Are Q-switched lasers for nevus of Ota really effective
in pigmented skin? Indian J Dermatol Venereol Leprol. 2012;78(2):187-9.
7. Ueda S, Imayama S. Normal-mode ruby laser for treating congenital nevi. Arch
Dermatol. 1997;133:355-9.
LASERS FOR TATTOO REMOVAL

INTRODUCTION
Laser removal of tattoos is probably the most satisfying and also the most
challenging indication for pigment specific lasers. The various types of tattoo
pigments ranging from inorganic materials to Azo dyes and their differing
absorption spectrum makes the task of choosing the correct laser even more
challenging. (Box 3.2) Though picoseconds lasers have emerged as a new
option, the challenges that we face in tattoo removal are two folds. Firstly
correctly interpreting the absorption spectrum of tattoos and then trying to
ensure rapid tattoo removal. The plethora of lasers used (Flow chart 3.1),
reflects the conundrum of tattoo removal, wherein numerous techniques are
still being experimented with to arrive at a perfect technique for removal of
the pigment.
Not all tattoos are cosmetic in nature and some are dictated by medical
need to demarcate a radiation treatment eld, or by traumatic embedment
Box 3.2 Pigments used by tattoo artists
Black
Carbon
Iron oxide
Logwood (extract from logwood tree)
Blue
Cobaltic aluminate (azure blue)
Green
Chrome oxide (Casalis green)
Hydrated chromium sesquioxide (Guignet green)
Malachite green
Lead chromate
Ferro-ferric cyanide
Curcumin green
Phthalocyanine dyes (copper salts with yellow coal tar dyes)
Red
Mercury sulfide (cinnabar)
Cadmium selenide (cadmium red)
Sienna (ochre: ferric hydrate and ferric sulfate)
Yellow
Cadmium sulfide (cadmium yellow)
Ochre
Curcumin yellow
Brown
Ochre
Violet
Manganese violet
White
Titanium dioxide, zinc oxide
Flesh
Iron oxides (variant of ochre)

Flowchart 3.1: Overview of lasers used in tattoo removal (Sardana K, 2013)
* Q-switched alexandrite laser (4 passes with an interval of 20 minutes between passes), used
for cosmetic Tattoo with multiple colors and flesh colored Iron oxide tattoo, used for traumatic
tattoos and tattoo allergy, QS Ruby with AFR (10,600 nm)/NAFR (1,550 nm) or AFR (2,940 nm)
with QS Nd:YAG
of foreign, pigmented matter in explosions and other accidents. This results

in a wide range of tattoo types (Table 3.2). The most important aspect is the
depth of the tattoo which may depend on the mode of placement, amateur or
professional, the latter being more difficult to treat as the pigment is deeper.
From the perspective of the physician and laser operator, the pigment
has to have a chemical composition that can be broken down with minimal
effort and without the formation of any toxic by-products. To prevent
such carcinogenic substances as much as possible, tattoo inks should be
completely free of azo compounds; it is unlikely that an aromatic amine will
occur as an impurity or be cleaved by a laser if no amines were used as starting
substances in manufacturing the pigments. But without any guidelines on
the same, this is unlikely to happen anyday sooner.
PIGMENT-SPECIFIC LASERS
For the selective removal of pigment, the laser light must penetrate far enough
into the skin to reach the target pigment, and must be highly absorbed by

Table 3.2 Types of tattoo and their response to laser
Tattoo
Pigment
Response
Side effect
Amateur
Most often black India

Ink, but also
various other organic
substances
Excellent: Complete
clearance can be
achieved with few
treatment sessions
Rare
Professional
Diverse pigments, often

inorganic
metal salts
Difcult as the
pigment density is
more and is deeply
placed
Inorganic dyes
an dazo dye are
particularly difficult
to treat
Pigmentary changes
and residual ink
frequently seen
Allergic reactions
possible
Cosmetic
Often brown, white or

esh-tones
enhanced with iron or
titanium
Difcult as the eshtone pigments poorly

target table by
available wavelengths
Ablative lasers have to
be used
Risk of paradoxical
darkening
Medicinal
Most often blueblack

India ink
Easily removed in 12
sessions
None
Iatrogenic
Metallic
Good response to
QSAlex and QSRL
Traumatic
Pigment from
gunpowder, tar,
and other particulate
matter
Varies
May be combustible
the pigment relative to the surrounding skin. Different pigments therefore

require different laser colors (Fig. 3.10). For example, red light is highly
absorbed by green tattoo pigments. In current practice, numerous lasers can
specifically target pigmented lesions, including red-light lasers (e.g. 694 nm
ruby, 755 nm alexandrite), green-light lasers (e.g. 532 nm frequency-doubled
Nd:YAG), and near-infrared lasers (e.g. 1,064 nm Nd:YAG). The wide range
of lasers that can be used to treat pigment is a result of the broad absorption
spectrum of melanin.
Though a detailed discussion on factors that determine laser tattoo
removal will follow, the available evidence suggests that there is graded
response of the various colored tattoos to the laser. Consequently, at least
three wavelengths are needed to cover most of the pigments. Thus possessing
a 532 nm, 694 nm and 1,064 nm laser, is a good starting point. As depicted
below (Table 3.3) the basic principle is of complementary color absorption.
Thus a green tattoo will respond to a red laser while a red tattoo to a green
lasers. This simplistic observation is confounded by the use of other shades
(Box 3.2) where an absorption spectrum analysis may be needed before
arriving at the appropriate wavelength.
Fig. 3.10: Absorption spectrum of common lasers used for tattoo removal
(Asclepion Laser Technologies, GmbH)
Table 3.3 Ideal laser for various tattoo pigments
Color
QS Nd:YAG
532 nm
QSRL
694 nm
QS Alex
755 nm
QS Nd:YAG
1,064 nm
Ablative
Black
Ideal
Ideal
India ink
Ideal
Brown
Used *
Blue
Ideal
Ideal
Green
Used*
Ideal
Used*
Orange
Used*
Red
Ideal
Purple
Used*
Flesh/White
Er:YAG/CO2
*Results are variable
LASER-INDUCED RESOLUTION OF TATTOO PIGMENT

The laser works by impaction and dissolution of the tattoo pigment. A little
researched topic is the course of events subsequent to this dissolution. Very
little is known regarding the natural history of an intradermally placed tattoo.
Initially, ink particles are found within large phagosomes in the cytoplasm of
both keratinocytes and phagocytic cells, including fibroblasts, macrophages,
and mast cells. The epidermis, epidermal-dermal junction, and papillary
dermis appear homogenized immediately after tattoo injection. At 1 month,
the basement membrane is reforming and aggregates of ink particles are
present within basal cells. In the dermis, ink-containing phagocytic cells

concentrate along the epidermal-dermal border below a layer of granulation
tissue closely surrounded by collagen. At 1 month, transepidermal elimination
of ink particles through the epidermis is still in progress, with ink particles
present in keratinocytes, macrophages, and fibroblasts. Reestablishment
of an intact basement membrane prevents further transepidermal loss. In
biopsies obtained at 23 months and 40 years, ink particles are found only
in dermal fibroblasts, predominantly in a perivascular location beneath
a layer of fibrosis, which had replaced the granulation tissue. Despite the
diverse tattoo pigment, the light and electron microscopy of all pigments are
remarkably similar.
It is common to observe that a tattoo becomes more indistinct, and blurred
with time presumably as a consequence of ink particles moving deeper into
the dermis. Indeed biopsies of older tattoos demonstrate pigment in the
lower dermis.
The consequence of laser on the tattoo is two fold. Firstly some part of the
tattoo ink is partially extruded through the scale crust that forms following
epidermal injury. A greater proportion of the ink particles may be fragmented
and released into the extracellular space and eliminated into the lymphatics
or rephagocytosed as laser-altered residual tattoo particles, perhaps with
altered optical properties. The last is important as in the R20R technique, the
laser optics do not take into consideration the tissue effects of repeated shots
of the laser.
VARIABLES EFFECTING TATTOO REMOVAL

A large study analysed the variables that effect tattoo removal using the Qs
Nd:YAG and Alex lasers. This study by Bencini et al. gives a realistic outcome
of results with lasers. The cumulative rates of patients with successful tattoo
removal were 47.2% after 10 sessions and 74.8% after 15 sessions. Smoking,
the presence of colors other than black and red, a tattoo larger than 30 cm2, a
tattoo located on the feet or legs or older than 36 months, high color density,
treatment intervals of 8 weeks or less, and development of a darkening
phenomenon were associated with a reduced clinical response to treatment.
This highlights the numerous variables influencing response rates and
the same should be considered when planning tattoo removal treatments
(Fig.3.11). The Kirby Desai scale is a useful index to predict the number of
sittings required for tattoo removal (Fig. 3.12) but does not take into account
the size depth and the duration of tattoo.
Patient-dependent Factors (Kirby et al.)

While a patient might believe that the laser treatment is the sole reason for
tattoo ink reduction, the theory behind tattoo removal involves the patients
Fig. 3.11: A depiction of the various lasers used for multicolored tattoos
own immune system. It is hypothesized that these laser-altered residual

particles are phagocytosed by the bodys lymphatic system.
Patients suffering from short- and long-term immunosuppression (i.e., via
chemotherapy, drug-induced, or a medical condition) may experience poor
healing, which can further lead to ink retention following laser treatments.
Individuals presenting with underlying immunosuppression should be
referred to the appropriate specialist for comprehensive care. Once the
condition has stabilized or resolved, they should be considered appropriate
candidates for laser tattoo removal treatment.
Tattoo-dependent Factors
Professional Vs Amateur
The number of sessions required varies though 510 sessions are standard for
amateur tattoos and 1520 for professional tattoos, even up to 25 sessions in
some cases.The variable depth is a big problem as shown in Figure 3.13.
In professional tattoos, the particles may reach as far as the subcutis;
depending on the location of the tattoo on the body, this can mean a depth of
5 mm or more. The penetration depth of the laser into the tissue is determined
by the wavelength (the two factors correlate proportionally) and the spot
size, which is usually limited to about 34 mm. The penetration depth of the
laser can be optimized by using the largest spot size possible (4 mm) and a
homogenous beam profile (Karsai et al.).
Fig. 3.12: Predicted number of sittings required for an amateur tattoo in an Indian
patient using the Kirby-Desai scale
Color (Tables 3.3 and 3.4)

In clinical practice, all laser systems (ruby, 1064 nm Nd:YAG, and alexandrite
lasers) have proven effective in treating black, black-blue, blue, and
brown inks. Red and orange tattoos only absorb light from the Q-switched
frequency-doubled Nd:YAG lasers (532 nm) and pulsed dye lasers (510 nm).
Green tattoos respond best to treatment with Q-switched ruby or alexandrite
lasers, purple, yellow, white and flesh-tone dyes do not yield satisfactory
results (Prinz, Ross (2001)).
An example of the complexities involved in tattoo removal is depicted in
(Fig. 3.11).
Fig. 3.13: Laser treatment of a amateur tattoo showing the variable whitening which
indicates the variation in depth of the tattoo pigment leading to erratic removal of
pigment
Table 3.4 A summary of lasers used for various tattoo pigments
Laser used
Violet*
Blue
Green
Red/brown*/orange/yellow
Black
532 mn
Nd:YAG
No
No
No
Yes/ Yes/ Yes/Yes
No
694 nm
Ruby
Yes
Yes
Yes
No/Yes/No/No
Yes
Yes
Yes
No/Yes/No/No
Yes
Yes
No
No/Yes/No/No
Yes
755 nm
Alex
1,064 nm
Nd:YAG
No
*Poor Response
Location
Experience shows that it takes longer to lighten tattoos in distal anatomical
regions such as forearms and calves. This may be due to slower lymphatic
transport, which in turn leads to delayed elimination of the color pigments.
Age
It is believed that older the tattoo, worse is the response as the macrophages
tend to engulf the pigment Also, the tattoo is deeper and thus a higher dose
and larger number of sittings are required.
Skin Type
Pigmented skin have delayed response as the epidermal pigment competes
with the light.
Scar/Granuloma
If the skin is palpably thickened because of tattoo-related permanent infiltrate
or scarring, (Fig 3.14), it is more difficult for the laser to penetrate the dermis,
and the pigment particles ability to absorb light will be affected.
Paradoxical Ink Darkening

Paradoxical darkening of tattoo ink can occur after Q-switched treatment and
has been reported in multiple ink colors. Certain colors including yellow,
white, peach, or pink may be susceptible to paradoxical ink darkening
secondary to reduction of ferric oxide to ferrous oxide, which leads to a
darkening of the ink. Another possibility to explain paradoxical ink darkening
may be the Tyndall effect, since tattoo pigments are found in the dermis and
can cause a diffraction of incident light.
Tattoos that experience paradoxical darkening often require additional
treatments to obtain complete ink resolution, but the newly darkened
ink may also be an unfortunate permanent consequence. Paradoxical ink
darkening can be a contributing factor to ink retention and patients who will
likely experience this phenomenon should be forewarned of the possibility
Fig. 3.14: A case of a tattoo with scarring noted before initiation of laser sessions.
This has medicolegal implications and the patient should be told of the pre-existent
scarring lest he notices it after completion of the laser sessions
that ink retention is a possibility following paradoxical color changes with

particular tattoo colors.
Non-responsive Tattoo Ink

Numerous tattoo ink formulations are now available. Although many inks
respond to laser treatment as anticipated, some tattoo ink formulations are
recalcitrant to treatment. The most common tattoo ink color is black and the
wavelength of light used most frequently to treat this color is 1,064 nm. Tattoo
artists will mix colors and ingredients and acknowledge that the formulations
themselves are not uniform, frequently change, and are poorly regulated.
Given the variability of these pigments, tattoo ink will occasionally present
that does not respond to the treatment as predicted. In these cases, patients
may experience ink retention and require more treatment sessions than
originally anticipated. Clinicians may need to use more than one wavelength
of light in these cases.
Undesired Pigmentary Alteration

Transient hyperpigmentation following Q-switched treatment is a wellestablished phenomenon upon complete resolution of tattoo ink following
laser treatment. Patients and novice practitioners may occasionally
confuse this hyperpigmentation with ink retention. Continued exposure
to laser light may only prolong this transient hyperpigmentation and thus,
treatments should cease once tattoo ink has resolved completely or at least
improved significantly. Prolonging the intervals between treatments, topical
hydroquinone and sun avoidance measures should be considered for any
patient that confuses undesired pigment alterations with ink retention.
Laser-dependent Factors
Fluence
The fluence can be increased by the reduction of the laser beam to a smaller
spot size area. However, this results in a longer treatment time. More
importantly, the effective treatment fluence is reduced at smaller spot sizes.
As a beam propagates into the skin, light scattering by the skin spreads the
beam radially outward on each side, which decreases the beams effective
fluence as it penetrates into the skin. This effect is more pronounced in smaller
spot sizes where the spreading of the beam is relatively large compared to the
incoming beam spot size (Fig. 3.15).
This is why the effective fluence within the skin of, for example, a 2 mm
incoming laser beam is approximately two times smaller than the effective
fluence of an 8 mm laser beam. This results in approximately two times lower
treatment efficacy when using a 2 mm spot size beam compared to an 8mm
spot size beam. When the incoming laser fluence is the same for both spot
Fig 3.15: Effect of spot size in Qsw laser. The scattering of light which is more when
the spot size is small, thus it is useful to increase the diameter in case of recalcitrant
lesion
sizes, the resulting effective fluence is lower not only on the surface but also
within the skin.
Based on the above concept (Fig. 3.15), larger spot sizes enable deeper
penetration and more effective treatment of pigment. Better beam profiles
also minimize epidermal damage and decrease bleeding, tissue splatter, and
transient textural changes. Of course, the practitioner can treat pigments
with smaller beam spot sizes if the laser fluence is adjusted accordingly.
For example, if the incoming fluence of a 2 mm laser beam is increased by
a factor of two, the penetration and the treatment efficacy resulting from
2mm and 8 mm laser beams become similar. This technique is successfuly
employed for Variable Square Pulse (VSP) skin rejuvenation and hair removal
treatments since VSP lasers are capable of generating sufficiently high laser
pulse energies in the millisecond pulse duration range. However, this is often
not a viable strategy for Q-switched lasers where high laser energies within
extremely short, nanosecond pulses are difficult to obtain.
Extremely high laser powers may damage laser optics and cause optical
breakdown in the air. For this reason, some commercially available devices
use a rapid sequence of two or more lower power laser pulses, instead of a
single giant pulse, to increase the total delivered laser fluence to the treated
tissue. Others have modified it as the R20R technique. But this has a singular
problem, as tissue characteristics change following the irradiation with a
laser pulse. This may reduce the pigment removal efficacy of subsequent
laser pulses.
Ideal Interval
Appropriate treatment interval has been rarely studies. It was initially hoped
that a condensed protocol of 3 sessions within a 7 to 10 days period, followed
by adequate for macrophage activity (3 months), would result in a rapid tattoo

removal with fewer total treatments but this was not found to help. Treatment
intervals of 1 month interval could interfere with macrophage activity,
because the pigment containing macrophages are laser targets as well as the
stationary pigment laden macrophages. Thus extending the interval to 23
months was ideal and lead to a 50% improvement after 3 sessions.
Sessions
It is difficult to predict the number of treatment sessions necessary for
tattoo removal. Frequently the initial treatment session produces a more
dramatic response than subsequent sessions. Very definite sites of clearing,
corresponding to laser impacts, are often visible. Other tattoos are strongly
unresponsive during early treatment phases, even though biopsies reveal
fragmentation of tattoo granules. The explanation of these differences in
response from one patient to another is likely to involve the efficiency of
mobile macrophages in removal of fragmented tattoo pigment debris, as
well as the density and amount of tattoo pigment present. The speed of the
macrophage response, as well as the maximum amount of pigment removed
per session, likely varies from patient to patient and to some extent from
treatment to treatment.
A few general assumptions can be safely made, larger and deeper the
tattoo more the sessions required. As a general rule, new tattoos treated with
Q-switched alexandrite lasers cleared faster, possibly because of the more
superficial location of a new tattoo.
Pulse Duration
Recently, Saedi N et al. have used a picosecond Alex laser for removing
tattoos. But importantly this would entail a picoseconds laser for each color
which would add to the cost of therapy. To date, no large-scale studies or
head-to-head unit comparisons have been performed with these devices
showing improved efficacy when compared to Q-switched devices. Thus, at
present the Q-switched technology is appropriate for tattoos.
Ideal Technique
A Polka-dot technique is employed. This means, gaps between consecutive
shots. These gaps then have to be treated with an additional treatment. This
technique reduces side effects related to the high absorption in very black
professional tattoos.
COMBINATION LASER THERAPY

Transepidermal elimination of the ink pigment could be further increased by
disrupting the dermoepidermal junction zone via fractional photothermolysis
(Wang et al.). The only issue is that the fractional technology is not very effective
for dermal pigmentation disorders and this method may require high density
and doses which may lead to more side effects. Recently a novel combination
of ultrapulse CO2 laser followed by Qsw Nd:YAG has been used successfully
for tattoos which can help shorten the number of sittings (Sardana K, 2013).
A example of this is depicted in Figure 3.16 and in the Atlas.
CONCOMITANT THERAPY
Imiquimod
Solis et al. used imiquimod to treat freshly applied tattoos on guinea
pigs. After 7 days, barely a trace of pigment could be histopathologically
detected; however, after 28 days, they observed fibrosis and a loss of dermal
appendages. When administered under optimized conditions, imiquimod
may be a nonsurgical means of removing fresh tattoos.
CONCLUSION
Most laser surgeons will graduate to using lasers for tattoos and will face
numerous scenarios that make it difficult to produce rapid results. A
Fig. 3.16: A tattoo being treated by the modified two step technique. First the epidermis
is ablated using the Er:YAG laser, is then followed by the QS Nd:YAG laser. Note: The
polka dot pattern, wherein in the first pass, a gap is ensured between subsequent laser
shots, which are then covered subsequently.
(Sardana K, et al. A promising split-lesion technique for rapid tattoo removal using
a novel sequential approach of a single sitting of pulsed CO2 followed by Q-switched
Nd: YAG laser (1064 nm). JCosmet Dermatol. 2013;12(4):296-305)
Mild graying to complete blackening of

the treated tattoo. Seen in white, eshcolored, red, brown, yellow, and crimson
pigmented tattoo
Pigments used for automobile paint and
printers ink can cause inammatory,
allergic hypersensitivity, granulomatous,
lichenoid and pseudolymphomatous
reactions
Usually used for masking a previous
tattoo
These particles are usually gravel, asphalt,
dirt, pencil, surgical pen, rework debris,
amalgam, or glass
Darkening of
tattoos
Emergent removal of
tattoos
In certain situations like interview,

marriages and army recruitment patients
are desirous of removal of tattoos in one
sitting
Tattoos in pigmented In dark pigmented skin (Type V/VI),

skin
results are slow and incomplete
Traumatic/
Iatrogenic tattoos
Double tattoos
Hypersensitivity to
pigments
Multicolored
tattoos
Clinical problem
Average sittings required vary from 610
sittings. Tattoo removal varies from 47.2%
after 10 sessions to 74.8% after 15 sessions
Colors, like yellow and orange, are known
to be highly resistant to treatment, and
red and green have a variable response
Multiple sittings are required with a high risk of

scarring
If pigment is carbon and graphite respond to
Q-switched lasers
In case of combustible material scarring may ensue
due to combustion in case lasers are used
The epidermal pigment may interfere with the laser
wavelength specially for multicolored or colored
tattoos due to the shorter wavelength used
Q-switched lasers require multiple sittings and
picoseconds laser are pigment specific and expensive
The Q-switched lasers are of no use in these situations
Absorption spectrum shows variable wavelength

requirement; Blue (625 nm), green (755 nm), red (575
nm), yellow (<520 nm) orange (<560 nm), tan (<560
mn) and flesh colored (<530 nm). In pigmented skin,
the shorter wavelengths used may be absorbed by
melanin and thus cause side-effects and also prevent
degradation of pigment in the dermis
This is primarily due to the use of ferric oxide (brown,
red, and pink) and titanium dioxide (white and eshcolored green, blue, and yellow pigments)
Comments
Various modifications and combinations have been
tried including the picosecond lasers
Table 3.5 An overview of lasers and modifications used for recalcitrant tattoos (Sardana K, 2013)
Scenario
Slow response
Our combination approach is

quick, safe and removes pigment
in 12 sitting
In most cases, ablative lasers are

the only option though in one
report a combination of PDL and
Q-switched laser has been used
Excision of the tissue and ablative
lasers are the only option
Recently a combination of AFr
with Q-switched laser has been
tried in 2 patients
A combination approach may be
a useful modality
Usually ablative lasers can be
used effectively. Another option
could be surgical excision of the
particle
Our combination approach may
be a simple cost-effective option
Combination lasers and ablative

lasers can be used. A trial and
error approach is needed in most
cases
Laser used
The various techniques are
depicted in (Fig 3.3)
summary of these scenarios and a suggested approach is given in Table 3.5,

though being a dynamic field, some practitioners may adopt other alternative
approaches.
At the end of the day, it is remarkable, how a plethora of issues, arise out
of the use of a largely cosmetic need, where the tattoo artist and the laser
practitioner are on two extreme ends. It is the authors view, that till FDA
regulates tattoo artists and colors, neither will the art of tattooing nor the load
of laser clinics be reduced in the foreseeable future making this probably the
most important indication of Qsw lasers.
BOOKS
1. Goldman MP, Ehrkich M, Kilmer SL. Treatment of tattoos. In: Goldman MP (Ed).
Cutaneous and Cosmetic Laser Surgery, 1st ed. USA, 2006:109-34.
2. Fitzpatrick RE, Goldman MP. Carbon dioxide laser surgey. In: Goldman MP,
Fitzpatrick RE (Eds). Cutaneous Laser Surgery, 2nd ed. USA; 1999. PP. 302.
BIBLIOGRAPHY
1. Anderson RR, Geronemus R, Kilmer SL, Farinelli W, Fitzpatrick RE. Cosmetic
tattoo ink darkening. A complication of Q-switched and pulsed-laser treatment.
Arch Dermatol. 1993;129(8):1010-4.
2. Alster TS. Q-switched alexandrite laser treatment (755 nm) of professional and
amateur tattoos. J Am Acad Dermatol. 1995;33(1):69-73.
3. Bencini PL, Cazzaniga S, Tourlaki A, Galimberti MG, Naldi L. Removal of tattoos
by Q-switched laser: variables influencing outcome and sequelae in a large
cohort of treated patients. Arch Dermatol. 2012;148(12):1364-9.
4. Beute TC, Miller CH, Timko AL, Ross EV. In vitro spectral analysis of tattoo
pigments. Dermatol Surg. 2008;34(4):50815; Discussion 15-6.4.
5. Karsai S, Pfirrmann G, Hammes S, et al. Treatment of resistant tattoos using a
new generation Q-switched Nd:YAG laser: influence of beam profile and spot
size on clearance success. Lasers Surg Med. 2008;40:139-45.
6. Kirby W, Chen CL, Desai A, Desai T. Causes and recommendations for
unanticipated ink retention following tattoo removal treatment. J Clin
AesthetDermatol. 2013;6(7):27-31
7. Leuenberger ML, Mulas MW, Hata TR, Goldman MP, Fitzpatrick RE, Grevelink
JM. Comparison of the Q-switched alexandrite, Nd:YAG, and ruby lasers in
treating blue-black tattoos. Dermatol Surg. 1999;25(1):10-4.
8. Prinz BM, Vavricka SR, Graf P, et al. Efficacy of laser treat-ment of tattoos using
lasers emitting wavelengths of 532 nm, 755 nm and 1064 nm. Br J Dermatol.
2004;150:245-51.
9. Ross EV, Yashar S, Michaud N, et al. Tattoo darkening and nonresponse after laser
treatment: a possible role for titanium dioxide. Arch Dermatol. 2001;137:33-7.
10. Saedi N, Metelitsa A, Petrell K, Arndt KA, Dover JS. Treatment of tattoos
witha picosecond alexandrite laser: a prospective trial. Arch Dermatol.
2012;148(12):1360-3.

11. Sardana K, Garg VK, Bansal S, Goel K. A promising split-lesion technique for
rapid tattoo removal using a novel sequential approach of a single sitting of
pulsed CO2 followed by Q-switched Nd: YAG laser (1064nm). J Cosmet Dermatol.
2013;12(4):296-30510.
12. Solis RR, Diven DG, Colome-Grimmer MI, et al. Experimental nonsurgical tattoo
removal in a guinea pig model with topical imiquimod and tretinoin. Dermatol
Surg. 2002;28:83-6.
13. Zelickson BD, Mehregan DA, Zarrin AA, Coles C, Hartwig P, Olson S, et al.
Clinical, histologic, and ultrastructural evaluation of tattoos treated with 3 laser
systems. Lasers Surg Med. 1994;15(4):364-72.
14. Ueda S, Imayama S. Normal-mode ruby laser for treating congenital nevi. Arch
Dermatol. 1997;133:355-9.
15. Wang CC, Huang CL, Lee SC, Sue YM, Leu FJ. Treatment of cosmetic tattoos
with nonablative fractional laser in an animal model: a novel method with
histopathologic evidence. Lasers Surg Med. 2013;45(2):116-22.
LASER TREATMENT OF COMMON PIGMENTED CONDITIONS

Some basic principles about therapeutic cure with lasers should be under
stood before attempting pigmented lesions specially in pigmented skin:
1. Dynamic conditions do not respond as well as static lesions: This
principle explains why conditions like lentigines and nevus of Ota tend
to respond better than say melasma, a classic dynamic lesion.
2. Low contrast lesions respond to lasers: In pigmented skin, melasma is
not a low contrast lesion,while in a fair skin type, it might be the case.
Thus the results of most procedures are disappointing in melasma.
3. Dermal disorders are poorly responsive in pigmented skin: The rapid
and predictable response of lentigines as compared to the slow, variable
response of nevus of Ota is explained by the effect of the competing
pigmented epidermis, which alters the laser physics dynamics.
LASERS USED
Pigment in epidermal lesions is located supercially, so shorter wavelength
devices can be used effectively despite their limited penetration depth. For
example, the 510 nm wavelength of the pulsed dye laser penetrates only
250m into the skin but is highly absorbed by melanin. The Q-switched ruby
and alexandrite lasers effectively treat both epidermal and dermal lesions
since their wavelengths are well absorbed by melanin and penetrate deeply
into the dermis. The 1,064 nm wavelength of the Nd:YAG laser penetrates
deeply but is poorly absorbed by melanin, making the 532 nm wavelength
a better choice when treating epidermal lesions. At the 510 nm and 532 nm
(green) wavelengths, hemoglobin competes with melanin for absorption
of light. Ultrashort (nanosecond range) pulses at these wavelengths cause
rupture of supercial blood vessels, which is evident clinically as purpura.
The efcacy and side effect prole of QS ruby and QS Nd:YAG (1,064 nm,
532 nm) lasers have been compared in the treatment of cutaneous pigmented
lesions, including lentigines, CALM, nevus of Ota, nevus spilus, Beckers
nevus, PIH, and melasma. With the exception of melasma for which poor
results are reported the QS ruby laser produced good-to-excellent results
(5095% clearing), as opposed to fair-to-good (2575% clearing) results for
the QS Nd:YAG for all remaining conditions.
While a summary of the conditions are given below, some representative
photographs are given in the Atlas that follows the text.
EPIDERMAL DISORDERS
Lentigines
Lentigines are extremely common hyperpigmented macules that are most
often due to chronic sun exposure and are then referred to as solar lentigines.
On pathology lentigines display increased single melanocytes along the basal

layer with elongation of club-shaped rete ridges.
Lasers Used
Qsw Devices
All three Q-switched lasers are highly effective for treating all types of lenti
gines. If properly performed, 12 sessions are sufficient. With one treatment
using a Q-switched laser, at least 50% clearing of lentigines is expected.
Milisecond Devices
Although less selective, non Q-switched (millisecond domain) KTP, 595 nm
pulsed-dye, ruby, alexandrite, and diode lasers may also be used to treat
lentigines. The advantages are less PIH. The logic is that long pulse lasers
have a longer millisecond pulse width, which result in more absorption by
target melanin and less absorption by competing chromophores such as
oxyhemoglobin, and surrounding pigmented skin. Also these lasers target
melanin by photothermolysis only. In contrast, QS lasers emit high-energy,
nanosecond radiation, causing both photothermal and photomechanical
effects. This paradoxically stimulates the surrounding melanin and
oxyhemoglobin are causing PIH.
IPL
Though this has been tried, in our experience, multiple treatments are
required and the large spot size, leads to complications in Indian skin. In fact,
IPL suffer from the classical catch 22 situation as if a low energy is used,
the results are poor while a high energy leads risk of injury to surrounding
normal skin.
Pearls/pitfalls
Always use a test spot to determine the optimal energy level. This is as in
our skin type hypopigmentation is a eventual result. Also consistent SPF 30
sunscreen is advisable as a tanned skin leads to a high test spot dose.
Level of Difficulty
Easy.
Bibliography
1. Kilmer SL, Wheeland RG, Goldberg DJ, Anderson RR. Treatment of epidermal
pigmented lesions with the frequency-doubled Q-switched Nd:YAG laser.
Acontrolled, single-impact, dose-response, multicenter trial. Arch Dermatol.
1994;130(12):1515-9.

2. Tse Y, Levine VJ, McClain SA, Ashinoff R. The removal of cutaneous pigmented
lesions with the Q-switched ruby laser and the Q-switched neodymium:yttriumaluminum-garnet laser. A comparative study. J Dermatol Surg Oncol.
1994;20(12):795-800.
Labial Melanotic Macules

Melanotic macules on the lip vermilion are a feature of several entities
including physiological racial pigmentation, Laugier-Hunziker syndrome,
and Peutz-Jeghers syndrome.
Laser Used
These can be treated using the QS ruby or QS alexandrite or frequencydoubled QS Nd:YAG lasers. In the case of the syndromes, patients should be
made aware that new macules will develop over time.
Level of Difficulty
Easy.
Nevus Spilus
A nevus spilus (speckled lentiginous nevus) consists of a background CALM
and scattered nests of nevi cells. Successful clearing of the darker nevocellular
component has been reported with the QSRL, but the CALM component
tends to recur.
Level of Difficulty
Easy.
Caf Au Lait Macules

The primary lesion are easy to diagnose but remarkably difficult to treat. The
pathology shows giant melanin granules.
Lasers Used
Qsw Lasers
QS Nd:YAG, QS ruby, and QS alexandrite lasers: Treatment of CALMs with
lasers is minimally successful and often unpredictable. Temporary lightening
or clearing can be achieved after multiple treatments. They frequently recur
which is seen in up to 50% of lesions even when clearing is initially achieved.
Treatment sessions are spaced at least 8 weeks apart and clearance requires
at least 24 treatment sessions.
Ablative Lasers
Er:YAG can be used but as can fractional lasers, but again the results are
disappointing.
Pearls/Pitfalls
Light-skinned patients are the ideal candidates for CALM removal, but
recurrences, residual hyperpigmentation, and incomplete pigment removal
are common. In Indian skin, the results are disappointing. A combination of
Er:YAG with a pigmented laser may be tried The most important pearl is not
to intervene and to forewarn the patient about the largely dismal response
rate.
Level of Difficulty
Difficult.
Bibliography
1. Alora MB, Arndt KA. Successful treatment of a cafe-au-lait macule with the
erbium:YAG laser. J Am Acad Dermatol. 2001;45(4):566-8.
2. Levy JL, Mordon S, Pizzi-Anselme M. Treatment of individual caf au lait macules
with the Q-switched Nd:YAG: a clinicopathologic correlation. J Cutan Laser Ther.
1999;1(4):217-23.
3. Polder KD, Landau JM, Vergilis-Kalner IJ, Goldberg LH, Friedman PM,
Bruce S. Laser eradication of pigmented lesions: A review. Dermatol Surg.
2011May;37(5):572-95. doi: 10.1111/j.1524-4725.2011.01971.x.
4. Shah S, Alster TS. Laser treatment of dark skin: An updated review. Am J Clin
Dermatol. 2010;11(6):389-97.
Ephelides (Freckles)
These are hyperpigmented small macules located on sun-exposed skin and
become darker in the summer and lighter in the winter. There is no increase in
the number of melanocytes on pathology, but there is an increase in melanin.
Lasers Used
Ephelides respond well to Q-switched laser treatment.
Level of Difficulty
Easy.
Seborrheic Keratoses
These respond better to pulsed CO2 lasers and Er:YAG as the results are much
faster than Qsw lasers and a single session is enough in most cases.
Level of Difficulty
Easy.
Beckers Nevus
Beckers nevus is a hyperpigmented, hair-bearing plaque that most commonly
occurs on the upper trunk or shoulder of males. These lesions may also be
associated with a dermal smooth muscle hamartoma.
Lasers Used
As the lesion has three components: the hair, the pigmented cells and a
dermal component, three lasers are ideally used in sequence (Fig. 3.17).
Treatment sessions should be spaced 812 weeks apart and 35 treatment
sessions are usually necessary.
1. QS ruby, QS Nd:YAG, and 1,550nm fractional erbium-doped fiber laser.
Of the QS lasers, the ruby is slightly more effective than the Nd:YAG. The
hyperpigmented component of Beckers nevi respond similarly to laser
treatment for CALMs. But frequent recurrences (within 612 months)
and post-inammatory hyperpigmentation is seen.
2. The terminal hairs can be removed with hair removal lasers.
3. Often a Er:YAG laser is used,which though not specific for the pigment
can remove or reduce the extent of the lesion. Clinical evaluation 2
years after treatment with the Er:YAG laser showed complete clearance
(100%) in 54% of the patients (n = 6) and clearance of > 50% in 100% of
the subjects and was superior to Qsw lasers.
4. Two male patients with Beckers nevi were treated with the 1,550 nm
wavelength erbium-doped fiber laser 6-10 mJ at 4 weeks intervals with
five to six treatment sessions. More than 75% of the pigment had faded by
1 month in both patients. There was no improvement in hypertrichosis.
Fig. 3.17: A figurative depiction of Beckers nevus and the combination of lasers
needed for optimal therapy
Pearls/Pitfalls
It should be understood that a combination of lasers is useful and even after
that also complete response may not be seen.
We routinely use a combination of fine ablation with Er:YAG( 5 j/cm2, 2
passes) followed by Qsw Nd:YAG (1,064 nm).
Level of Difficulty
Difficult.
Bibliography
1. Glaich AS, Goldberg LH, Dai T, Kunishige JH, Friedman PM. Fractional
resurfacing: a new therapeutic modality for Beckers nevus. Arch Dermatol
2007;143:1488-9.
1. Lapidoth M, Adatto M, Cohen S, Ben-Amitai D, Halachmi S. Hypertrichosis
in Beckers nevus: effective low-fluence laser hair removal. Lasers Med Sci.
2014;29(1):191-3.
2. Trelles MA, Allones I, Moreno-Arias GA, Vlez M. Beckers naevus: acomparative
study between erbium: YAG and Q-switched neodymium:YAG; clinical and
histopathological findings. Br J Dermatol. 2005;152(2):308-13.
DERMAL DISORDERS
Q-switched lasers have revolutionized the treatment of dermal pigmented
lesions including: melanocytic nevi, nevus of Ota, and melasma. But it must
be appreciated that as a thumb rule, deeper the pathology, slower the results.
The Q-switched ruby, alexandrite and 1,064 nm Nd:YAG are the most
commonly used lasers. All of these lasers are still within the absorption
spectrum of melanin yet also have wavelengths that is long enough to penetrate
into the dermis. Broad band light sources (such as IPL) lack wavelength
specicity and have longer (ms range rather than nanosecond range) pulse
durations, making them unsuitable for treating dermal pigmented lesions.
We have developed a simple tool to modify the lasers used in accordance
with the condition. Thus if the target particle is large, a millisecond or
microsecond laser can be used with equally good results. This principle
is used in in removing the acquired melanocyte nevus, where a Er:YAG or
pulsed CO2 can have excellent results if used properly (Fig. 3.18).
Acquired Melanocytic Nevi

These are classified into junctional, dermal and compound types depending
on the site of nevus cells. The AMN is a useful condition to understand the
principle of combination of lasers, thus we will dwell on it in detail.
Fig. 3.18: Effect of pigment selective and ablative lasers in removal and recurrence of
melanocyic nevi. A properly used ablative lasers may achieve excellent results with
minimal recurrence.
(Sardana K, et al. Optimal management of common acquired melanocytic nevi
(moles): current perspectives. Clin Cosmet Investig Dermatol. 2014;7:89-103)
Lasers Used
The lasers used for CAMN range from pigment-selective lasers to ablative
lasers. The use of lasers in CAMN (moles) is complicated by many practical
issues and scenarios which have to be properly understood before attempting
this mode of therapy (Fig. 3.18).
Principles of Therapy
Like any other indication, the use of lasers in pigmented lesions begins at the
helm of laser physics and depends on the absorption spectra of the target
chromophore, which is believed to be the melanocyte (melanosome). The
spectrum of lasers used ranges from the green lasers [(pulsed dye, Q-switched
(Qsw), and neodymium (Nd):yttrium aluminum garnet (Nd:YAG) 532) to the
far-infrared lasers (CO2 10,600 nm and erbium (Er):YAG 2,940 nm)]. Except
for the ablative lasers, the rest are strongly absorbed by melanin.
The second important proviso is to minimize heat damage, which
requires optimal setting of the pulse duration of the laser. A laser with a pulse
duration less or equal to the thermal relaxation time (TRT) of the target tissue
should be employed. This, in turn, depends on the size of the target tissue
which dictates TRT. This ranges from 0.25 s to 1.00 s for the melanosome
to 0.1ms (100 s) for the melanocyte. Although the nanosecond lasers (Qsw)
have been conventionally used to treat pigmented lesions, the same principle
cannot apply to CAMN. The geometry (and therefore, the microscopic
characteristics) of the lesion is important, and as the nevus is composed of
melanocytes in aggregates (collectively of a size of 100 m in diameter) this
corresponds to a TRT of about 10 msec, thus accounting for the use of normal
mode (msec) and far-infrared lasers to treat CAMN.
The third requirement is to achieve an adequate depth to target the
chromophore for which the red (ruby 694 nm, alexandrite 755 nm) and nearinfrared (Qsw Nd:YAG 1,064 nm) lasers (approximately 6001,100 nm) are
ideal.
Based on these three principles, the devices useful for treating
melanocytic lesions are of two basic classes: infrared skin resurfacing lasers
and pulsed lasers/intense pulsed light (IPL) lasers. The pulsed lasers are
further divided into long-pulse (msec) devices, which tend to target relatively
large pigmented structures such as hair follicles and nests of nevus cells,
and short-pulse (Qsw nsec lasers) devices, which are capable of targeting
individual pigmented cells.
Histologically, CAMN have both isolated nevomelanocyte cells, and
nests, or clusters, of cells. Thus, a mixture of lasers targeting both should
ideally be used, with the use of short (ns) pulses and long (ms) pulses. This
is the reason why melanocytic nevi are better treated with a combination of
lasers.
Clinical Experience
A side-by-side comparison of QS alexandrite (755 nm, 100 ns, 3 mm, and
6.0 J/cm2) and the Nd:YAG (1,064 nm, 10 ns, 3 mm, 6.0 J/cm2) lasers for
treatment of benign acquired melanocytic nevi with a uence of 6.0 J/cm2
and a 3 mm spot size was done to opposite halves of a large (1.5 cm) or to two
small (0.7 mm) adjacent nevi. After one treatment, 10% lightening was noted
for both lasers whereas after three treatments, more lightening was observed
after alexandrite (60%) than after Nd:YAG (30%) laser treatment possibly
explained by the more supercial location of the target melanosomes (i.e.at
the dermalepidermal junction) in common acquired melanocytic nevi, as
compared to nevus of Ota, which respond better to the longer and deeper
penetrating wavelength of the QS Nd:YAG (1,064 nm) laser.
Some basic principles can be used to treat acquired melanocytic nevi:
1. Lighter nevi respond best to shorter wavelengths that maximize melanin
absorption, while darker nevi typically respond to any wavelength within
the melanin absorption spectrum. Multiple treatments are frequently
necessary for optimal lightening. Clinical lightening is also associated
with the development of a subtle microscopic scar up to 1 mm thick that
obscures residual nevus cells.
2. The goal of complete resolution is difficult in most cases and recurrence
after laser treatment is common. This is as there may be persistence of
nevus cells containing little pigment located in the deeper dermis that
are shielded from laser radiation by the more pigmented supercial
cells.
3. Deep dermal nevi and thick moles do not respond to the Q-switched
laser. The short pulsed Er:YAG laser is useful in such cases (5.2
14 J/cm2).
Protocol Used (Flow chart 3.2)

As shown in the Figure 3.18, there is little advantage in using conventional
nanosecond lasers as there is a high chance of recurrence. But if employed,
the chance of recurrence is to be expected. Good pulsed laser due to the
added coagulative effect has better results.
1. The logic employed in the use of combination lasers (normal mode
and Qsw ruby laser, CO2 and Qsw alexandrite, CO2 and Qsw frequencydoubled Nd:YAG laser, CO2 and Qsw ruby laser) is to expose the otherwise
unaffected, deep-sited nevomelanocytes to the pigment-specic laser.
2. Nevus cells in the supercial dermis are additionally removed by the
CO2 laser.
3. Alternatively, for a smaller mole (1.5 cm), a short-pulsed Er:YAG
would be an ideal tool, as apart from the pulse duration (3001,000 sec)
the Er:YAG laser has a predictable depth (5 m/J/cm2), minimal thermal
damage (2030 m), and a high absorption coefcient of water (Er:YAG
12,800 cm1; CO2 800 cm1), and is thus capable of a far ner and safer
supercial ablation, with minimal sequelae. A comparison of various
modalities at our center revealed that the combined or pulsed ablative
method is better than using the Qsw lasers for CAMN.
Pearls/Pitfalls
The use of a laser is to be reserved for benign nevomelanocytic lesions
exhibiting little to no atypia. If any doubt exists about the clinical diagnosis, a
biopsy should be performed prior to laser treatment.

Flow chart 3.2: An algorithm depicting the role of various lasers in the treatment of
acquired benign melanocytic nevi (Sardana K, 2014)
Use a laser depending on the pathology. In our experience, pigment

specific laser requires more sessions while a ablative laser requires 12
sessions.
A biopsy is useful in case of recurrence or atypia.
Bibliography
1. Baba M, Bal N. Efcacy and safety of the short-pulse erbium:YAG laser in the
treatment of acquired melanocytic nevi. Dermatol Surg. 2006;32:256-60.
2. Duke D, Byers R, Sober AJ, et al. Treatment of benign and atypical nevi with the
normal-mode ruby laser and the Q-switched ruby laser: Clinical improvement
but failure to completely eliminate nevomelanocytes. Arch Dermatol. 1999;135:
290-6.
3. Rosenbach A, Williams CM, Alster TS. Comparison of the Q-switched alexandrite
(755 nm) and Q-switched Nd:YAG (1064 nm) lasers in the treatment of benign
melanocytic nevi. Dermatol Surg. 1997;23:239-45.
4: Sardana K, Chakravarty P, Goel K. Optimal management of common acquired
melanocytic nevi (moles): current perspectives. Clin Cosmet Investig Dermatol.
2014;7:89-103. eCollection 2014. Review.

5. Vibhagool C, Byers R, Grevelink JM. Treatment of small nevomelanocytic nevi
with a Q-switched ruby laser. J Am Acad Dermatol. 1997;36:738-41.
Congenital Melanocytic Nevi

The variable depth of the nevus cells, concomitant presence of hair in a
majority of cases and epidermal changes makes the results of lasers erratic
and unpredictable.
Lasers Used
Although Q-switched lasers may effectively lighten congenital nevi, there is
frequently repigmentation due to persistence of nevus cells within the deeper
reticular dermis and within adnexae.
Combination of Lasers
Pigment Laser
A split nevus study showed that a combination of Q-switched and normalmode ruby laser (NMRL) was better than NMRL alone with a marked decrease
in nevus nests at the dermal-epidermal junction, papillary and reticular
dermis. In theory, millisecond-domain pulses are more appropriate than
Q-switched pulses for treating thick lesions such as congenital nevi because
they produce less selective thermal damage, destroying entire nests of cells
rather than individual pigmented cells.
Ablative Lasers with Pigment Lasers

Combinations of pulsed CO2 and Er:YAG or with Qsw Lasers have been used.
The principle being that the ablative laser remove the bulk of the tissue, but
being non-specific for the pigment, the pigment specific laser is then used
to target the nevus cells. Compared with macular CMN, mammillated CMN
show a marginally better response tolasertreatment. Also CMN on the limbs
respond poorly (August PJ).
Surgical Excision Followed by Er:YAG

The basic principle is a surgical/shave excision followed by Er:YAG. This
method is blind as the Er:YAG has affinity for water and not the pigmented
nevus cells.
Pearls /Pitfalls
As congenital nevi have the potential to transform into malignant melanoma,
and residual nevus cells persist in the dermis after laser treatment, cautious
long-term follow-up of nevi treated with lasers is required. Also lasers should
be restricted small and medium-sized CMN. But as there are very few RCT
in literature and the complexities of surgical excision does not eliminate the
nevus cells or the risk of melanoma, a close regular follow-up should be the
aim. Thus a wait and watch approach is better as most of the therapeutic
interventions do not decrease the risk of melanoma.
Bibliography
1. Ablation with surgical excision for treating medium-sized congenital melanocytic
nevus. Ann Dermatol. 2009;21(2):120-4.
2. Al-Hadithy N, Al-Nakib K, Quaba A. Outcomes of 52 patients with congenital
melanocytic naevi treated with UltraPulse carbon dioxide and frequency doubled
Q-Switched Nd-Yag laser. J Plast Reconstr Aesthet Surg. 2012;65(8):1019-28.
3. August PJ, Ferguson JE, Madan V. A study of the efficacy of carbon dioxide and
pigment-specific lasers in the treatment of medium-sized congenital melanocytic
naevi. Br J Dermatol. 2011;164(5):1037-42.
4. Lim JY, Jeong Y, Whang KK. A Combination of dual-mode 2,940 nm Er:YAG laser.
Melasma
It is said that a medical condition with no cure, has many treatments. While
in medicine, common cold is a classic example, in dermatology, this honor
can be safely bestowed upon melasma. Every possible intervention from
triple combination creams (TC), peels to lasers have been tried, but as is the
universal experience, probably, TC creams form the mainstay of therapy.
Transient results have been seen for the epidermal subtype, but dermal
melasma and the mixed type which constitute the majority of patients in
pigmented skin are difficult to treat.
Two recent reviews aptly summarize the present evidence on melasma.
The use oflasersfor the treatment ofmelasmacannot be recommended, due
to unpredictable safety and efficacy, time-limited clinical improvement, and
no clear benefit over conventional treatments. Thus probably melasma is
natures way to compensate for the high ambient UV flux in tropical countries
and any method to remove it would probably lead to indifferent results and
rapid recurrence.Though we have no experience in treating fair skin types, in
darkly pigmented skin melasma should not be a favored indication for laser
therapy.
Lasers Tried
Pigment Specific
Laser toning involves the use of large spot size, and a low-fluence, QS
1,064-nm Nd:YAG laser (6 to 8 mm spot size, 1.62.3 J/cm2). The results,
without any additional therapy, are variable even in fairer skin types, with a
large number of cases, reporting mottled depigmentation. In our patients, a
high degree of disconcerting hyperpigmentation has been noted.
Fractional Lasers
The principles of laser therapy involves a pertinent target (melanocytes in
melasma), appropriate wavelength and the right pulse duration.The fractional
lasers are selective for water and their pulse duration is in milliseconds unlike
the microsecond TRT of melanocyte making them intrinsically inappropriate
in melasma. This coupled with the fact that only a fraction of the skin is
damaged, makes the technology inherently ineffective for melasma (Fig. 3.19).
Fractionated laser treatment may work by expelling columns of microscopic
epidermal debris that contains melanin but is probably insufficient to make
a clinical difference. The data suggests a high rate of repigmentation and
sometimes even an increase in pigmentation after the treatment makes it a
risky option in a pigmented skin.
Fig. 3.19: The mode of action of fractional lasers in melasma

(Sardana K, Garg VK. Lasers are not effective for melasma in darkly Pigmented Skin (J
Cutan Aesthet Surg. 2014;7(1):57-60)
On the contrary, if a fractional,pigment specific laser is used the results

are better, as seen by the results of the fractional ruby laser (Figs 3.20A to C)
and probable the fractional thulium laser.
IPL
In our opinion, there is little practical use in using this technology.
Er:YAG
A low fluence(12 J/cm2) Erbium peel has been tried but again is inadvisable
in pigmented skin.
Literature Review
An overview of the literature (Table 3.6) reveals certain salient facts that should
have a sobering effect on the unbridled enthusiasm of laser practitioners who
use this therapy for melasma specially in pigmented skin.
1. Objective Vs Subjective: It must be emphasized that MASI is a highly
subjective tool and the use of this and the often used percentile scoring
is never of any practical use as the improvement does not mirror the
actual clinical results.
2. The pigment in the epidermis alters the laser physics dynamics specially
in pigmented skin accounting for the variable results. Also the pigment
in melasma is not homogeneous either in distribution or depth and
studies have to be structured to account for a similar type of melasma
(epidermal/dermal or mixed).
3. All the lasers tried for melasma, including the pigment specific lasers
(Q-switched, long-pulsed lasers and IPL), ablative lasers (Er:YAG), and
fractional lasers have had indifferent results (Table 3.6). Transient results
have been seen for the epidermal subtype, but dermal melasma and the
mixed type which constitute the majority of patients in pigmented skin
are difficult to treat.
4. Though peels have been touted as an useful intervention it is a universal
practical experience that without TC creams (triple combination
creams) the results are not great, especially in pigmented skin. This is
probably as deep peels (papillary dermis level) which are useful in the
common mixed dermal melasma cases, are difficult to use in pigmented
skin due to their potential for PIH. Hurley in their study pointed out that
a TC cream would have superior results to the chemical peel, which is
the real-life scenario, though few authors admit this upfront.
5. A combination of TC creams/peels plus laser is an admission of the fact
that probably assisted therapy is better which puts a question mark on
the role of lasers per se.
Figs 3.20A to C: A series of patients treated by the fractional mode Q-switched ruby
laser tattoo star for melasma (Courtesy: Asclepion laser technologies GmbH)
Fractional thulium
laser (1,927 nm)
Qsw Nd: YAG

1,064nm
Fractional Qsw
694 nm ruby laser
Low dose Nd:YAG

1,064 nm
Low fluence
Qsw Nd:YAG
(1,064 nm)
Low dose 1
Qsw Nd:YAG
(1,064 nm)
Polder KD et al., 2012
Zhou X et al., 2011
Jang WS et al., 2011
Suh KS et al., 2011
Chan NP et al., 2010
Choi M et al., 2010
Monotherapy
Therapy
20 patients
FP-III-IV
5 Asian patients
23 Korean patients
FP III-V
15 Korean patients
Dermal/mixed
melasma
50 patients
FP IV-VI
14 patients
Demography
CS
Trial
2.03.5 J/cm2
Spot size 6 mm:
5 sessions at weekly
interval
1.63.5 J/cm2
Spot size: 68 mm
650 sessions
(22.67)
24 J/cm2
Spot size : 4,6,8 mm
10 sessions (once/
week)
6 sessions at 2 weeks
interval
2.5-3.4 J/cm2
Spot size: 6 mm
9 sessions/weekly
10-20 mJ, 6-8 passes,

34 sessions/4
weekly
Dosages
Mexameter,
cutometer,
chromameter,
corneometer,
visiometer
UV photographic
images
MASI satisfaction
index
MASI, skin
reflectance
MASI, Melanin
Index
Blinded physician
and patient
assessment
(subjective)
Assess
Table 3.6 Chronological summary of the salient work on lasers and their combinations in melasma
Author
Contd...
L value increased and

melanin index decreased
All patients failed to show

improvement in melasma
Mean MASI decreased

significantly even at 3 month
f/u visit
Mean decrease in MASI

15.1 to 10.6. Skin reflectance
increase from 56.6 to 59.9
Mean decrease in MI by
35.8%
(p < 0.001)
MASI decreased by 61.3%
(p < 0.001)
70% had >50% clearance
51% decrease in MASI at 1

month follow-up
(p < 0.05)
Results
IPL
Er:YAG
AFR(Er:YAG)
NAFR(Er:Glass)
Qsw Nd:YAG
Sardana K* et al.
Microderm abrasion
with Qsw Nd:YAG
with HQ and
sunscreens
1,064 nm Qsw Nd:

YAG Laser with 30%
GA peels
Vs Laser
monotherapy
Qsw Nd:YAG with 2%

HQ vs
2% HQ
Up CO2 laser and

Qsw alexandrite laser
(QSAL)
vs
QSAL alone
Kauvar AN, 2012
Park KY et al,
2011
Wattanakrai P et al.,
2010
Angsuwarangsee S
et al., 2003
Combination
Therapy
Therapy
Author
Contd...
6 Thai patients
FP IIV
refractory melasma
22 patients
Dermal/
mixed melasma/
FP II- IV
16 patients
Mixed melasma
27 female patients
FP II-IV
Mixed resistant
melasma
3 IPL
2 Er:YAg
7 AFR
1 NAFR
2 Nd:YAG
Demography
SF
RCT
SF
RCT
SF
Trial
CO2: 300 mJ;

Power: 5W; Spotsize:
3 mm
QSAL: 57 J/cm2 Spot
size: 3 mm
3.03.8 J/cm2
Spot size: 6 mm
5 sessions at weekly
intervals
Laser: 2.02.3 J/cm2,

6 mm spotsize
6 sessions (once/
week)
GA peels: 3 sessions
(once/2 weeks)
1.62.0 J/cm2 /4
weeks
Average no. of
sessions2.6.
22 J/cm2
5 J/cm2
90 J/cm2
70 mJ/mb
56 J/cm2
Dosages
mMASI
and the Melanin
index score
Colorimetric
(objective) and
mMASI
(subjective)
Mexameter
mMASI
Blinded
comparison of
digital photographs
using quartile
system
(Subjective)
MASI
percentile score
Assess
Contd...
Combination treatment had

a statistically significant
reduction compared to
QSAL side
73% patiens in the

combination group had
excellent results
Combined therapy
32.6% improvement with
mexameter and 37.4% in
mMASI
Vs
22% and 16.7%, respectively
by laser alone
(p < 0.05)
40% patients achieved >95%

clearance
81% patients achieved >75%
clearance
Remission lasted 6 months
The results with AFR, NAFR

and IPL were disappointing
With Er:YAG and Qsw
Nd:YAG temporary
Results
IPL with TC (4% HQ)

cream
vs IPL with control
cream
PDL and TC
vs TC cream
TC alone
vs
AFR(CO2)
vs combination
therapy
NAFR 1,550 nm
vs
TC (5% HQ)
Passerson T et al.,
2011
Trelles MA et al.,
2010
Wind BS et al., 2010
Therapy
Goldman MP et al.,
2011
Combination
Therapy With TC
Creams
Author
Contd...
29 patients
30 females
FP II-IV
17 patients
FP II-III
56 patients
Symmetrical
melasma
Demography
RCT
SF
RCT
SF
RCT
SF
Trial
MASI, satisfaction
index
MASI, Satisfaction
index
MASI
Assess
15 mJ/mb,
(PGA), patients
20002500 MTZ/cm2 satisfaction,
45 sessions vs
(PhGA), melanin
TC for 15 weeks
index, and lightness
(L-value)
High power fixed

pulse width, low
frequency
710 J/cm2
Pulse duration:1.5 ms
3 sessions at 3 weekly
interval
2 IPL treatments at 2
and 6 weeks
Dosages
Contd...
Mean PGA and satisfaction

index were significantly
lower for laser treated site.
PhGA, melanin index,
and L-value showed a
significant worsening of
hyperpigmentation at the
laser side. At 6 months
follow-up, most patients
preferred TC
100% improvement in
all 3 groups, results were
maintained, however, only
in combination
group at 12 months
Greater patient satisfaction

in combination group
Significant improvement
in melasma severity in the
combination group vs IPL
alone
Results
Low dose Qsw Nd:YAG

1,064 nm with pre and
post TC cream
Jeong SY et al., 2010
13 patients
FP III- IV
Demography
RCT
SF
cross
over
Trial
3.03.8 J/cm2
6 mm spot size
5 sessions (once/
week)
Dosages
Lightness index/
Colorimetry)
Assess
Mean MASI decreased
significantly on laser side
Results
HQ, Hydroquinone; FP, Fitzpatrick type; AFR, Ablative fractional laser; NAFR, non-ablative fractional laser; O, observational therapy; RCT, Randomized control trial;
SF, split face trial; CS, case series; mMASI, Modified melasma area and severity index score; PGA, Patients global assessment; PhGA, physicians global assessment;
Combinations with microdermabrasion, Up CO2, AFR, HQ, Peels and QSw Alex ; * Data of the laser clinic (200812)
Therapy
Author
Contd...
6. Fractional laser do not target melanin but target water so their use
in melasma make little logical sense. While the theory that they can
shuttle out the pigment is elegant, it ignores the fact that the pigment
reverts back rapidly, sometimes making it worse than before! In fact with
the fractional lasers, a rebound hyperpigmentation has been noted in
our analysis which is similar to the results noted by Karsai S et al.
Pearls/Pitfalls
If lasers are attempted, scruplulous sunscreen use (preferably a physical
block) with the use of a midpotent steroid for a week should be used. After
that till 21 days, which is believed to be the time by which PIH appears in the
majority of cases, a non-HQ/tretinoin based cream should be used.
Bibliography
1. Angsuwarangsee S, Polnikorn N. Combined ultrapulse CO2 laser and Q-switched
alexandrite laser compared with Q-switched alexandrite laser alone for refractory
melasma: split-face design. Dermatol Surg. 2003;29:59-64.
2. Chan HHL. Pigmentation and Hypopigmentation: Benign pigmented lesions. In
Raulin C, Karsai S, (Eds). Laser and IPL technology in dermatology and aesthetic
medicine, Ist edition. London Springer-Verlag Berlin Heidelberg; 2011. p.151-3.
3. Chan NP, Ho SG, Shek SY, Yeung CK, Chan HH. A case series of facial
depigmentation associated with low fluence Q-switched 1,064nm Nd:YAG laser
for skin rejuvenation and melasma. Lasers Surg Med. 2010;42:712-9.
4. Choi M, Choi JW, Lee SY, Choi SY, Park HJ, Park KC, et al. Low-dose 1064-nm
Q-switched Nd:YAG laser for the treatment of melasma. J Dermatolog Treat.
2010;21:224-8.
5. Goldberg DJ. Pigmented lesions, tattoos, and disorders of hypopigmentation.
In:Laser dermatology pearls and problems, Ist edition Massachusetts: Blackwell
Publishing; 2008. p. 91-3.
6. Halachmi S, Haedersdal M, Lapidoth M. Melasma and laser treatment: an
evidenced-based analysis. Lasers Med Sci; 2013.
7. Jang WS, Lee CK, Kim BJ, Kim MN. Efficacy of 694-nm Q-switched ruby
fractional laser treatment of melasma in female Korean patients. Dermatol Surg.
2011;37:1133-40.
8. Kar HK, Gupta L, Chauhan A. A comparative study on efficacy of high and low
fluence Q-switched Nd:YAG laser and glycolic acid peel in melasma. Indian J
Dermatol Venereol Leprol. 2012;78(2):165-71.
9. Karsai S, Raulin C. Fractional photothermolysis: a new option for treating
melasma? Hautarzt. 2008;59(2):92-100.
10. Kauvar AN. Successful treatment of melasma using a combination of
microdermabrasion and Q-switched Nd:YAG lasers. Lasers Surg Med.
2012;44:117-24.
11. Lee HI, Lim YY, Kim BJ, Kim MN, Min HJ, Hwang JH, et al. Clinicopathologic
efficacy of copper bromide plus/yellow laser (578 nm with 511 nm) for treatment
of melasma in Asian patients. Dermatol Surg. 2010;36:885-93.

12. Passeron T, Fontas E, Kang HY, Bahadoran P, Lacour JP, Ortonne JP. Melasma
treatment with pulsed-dye laser and triple combination cream: a prospective,
randomized, single-blind, split-face study. Arch Dermatol. 2011;147(9):1106-8.
13. Polder KD, Bruce S. Treatment of melasma using a novel 1,927-nm fractional
thulium fiber laser: a pilot study. Dermatol Surg. 2012;38:199-206.
14. Polnikorn N. Treatment of refractory melasma with the MedLite C6 Q-switched
Nd:YAG laser and alpha arbutin: a prospective study. J Cosmet Laser Ther.
2010;12:126-31.
15. Rivas S, Pandya AG. Treatment of melasma with topical agents, peels and lasers:
an evidence-based review. Am J Clin Dermatol. 2013;14(5):359-76.
16. Sardana K, Chugh S, Garg VK. Which therapy works for melasma in
pigmentedskin: lasers, peels, or triple combination creams? Indian J Dermatol
Venereol Leprol. 2013;79(3):420-2.
17. Suh KS, Sung JY, Roh HJ, Jeon YS, Kim YC, Kim ST. Efficacy of the 1064-nm
Q-switched Nd:YAG laser in melasma. J Dermatolog Treat. 2011;22:233-8.
18. Trelles MA, Velez M, Gold MH. The treatment of melasma with topical
creamsalone, CO2 fractional ablative resurfacing alone, or a combination of the
two: a comparative study. J Drugs Dermatol. 2010;9:315-22.
19. Wattanakrai P, Mornchan R, Eimpunth S. Low-fluence Q-switched neodymiumdoped yttrium aluminum garnet (1,064 nm) laser for the treatment of facial
melasma in Asians. Dermatol Surg. 2010;36:76-87.
20. Zhou X, Gold MH, Lu Z, Li Y. Efficacy and safety of Q-switched 1,064-nm
neodymium-doped yttrium aluminum garnet laser treatment of melasma.
Post-inflammatory Hyperpigmentation
PIH occurs due to hemosiderin and/or melanin deposition. Because this
condition arises due to inflammation, it is important to use low fluences and
ensure that the patient does not develop significant post-treatment erythema
to provoke additional PIH. For this reason, test spots are encouraged prior to
treating large areas.
Lasers Used
Vascular lasers
Vascular lasers, such as the 595nm LPDL, target mainly oxyhemoglobin, and
can be used to treat the vascular component of the inflammatory process.
Fractional Lasers
The laser system currently used most often for PIH is the fractional
photothermolysis system, even though treatment with this laser has been
reported to induce PIH itself. The fractional Er:YAg and possibly the thulium
laser may prove to be useful in this regard.
Pearls/Pitfalls
Prevention is a better option which can be achieved by effective sun
protection pre- and post-procedure, the use of long-pulsed lasers, cooling,
diascopy, and lower fluences.
We prefer administering hydroquinone-free products include compounds
such as kojic acid, and arbutin to prevent PIH. Post-laser tretinoin based
compounds may cause irritation and aggravate PIH.
This has been extensively covered in the chapter on complications and
the appendix of the book.
Nevus of Ota/Ito
Nevus of Ota
Nevus of Ota (also known as oculodermal melanoma or nevus fuscoceruleus
ophthalmomaxillaris) is a mottled, blue-grey macule that is usually located
unilaterally within the distribution of the rst and second branches of the
trigeminal nerve.
Lasers Used
It must be appreciated though, the Qsw lasers are the mainstay, there are
variations in the dose, fluence and sessions required depending on the depth,
size and color of the lesion.
Qsw Lasers
Q-switched lasers are extremely helpful in treating nevus of Ota. The degree
of lightening is usually directly proportional to the number of treatments
performed. Lightening of 70% or more has been reported in the majority of
patients treated four or ve times with the QSRL.
A few basic principles that have emerged from their use are:
1. Early QSRL treatment of nevus of Ota in children results in fewer required
sessions and complications, but recurrence is still a concern.
2. Multiple treatment sessions with QSRL increases response rate.
3. QS Nd:YAG is superior to QS Alex in subjective assessments of lightening,
but no statistical difference in efcacy has been shown.
4. QS Alex treatment is efcacious and can be without side-effects.
Histologic evidence demonstrates laser-induced elimination of upper
dermal pigmentation without epidermal disruption.
Combination of Lasers
1. Scanned CO2 with Qsw Laser: Mauskiatti et al. demonstrated greater
clearing of bilateral nevus of Ota like macules with a combination of
carbon dioxide (CO2) and Q-switched ruby laser (QSRL) treatment than
with QSRL alone.
2. Fractional laser: There are reports of the use of 1440 nm and 1550 nm
fractional lasers, which ostensibly help in better penetration of the
pigment specific laser. They are unlikely to appreciably improve the
condition by itself.
3. Combination of various lasers (Felton SJ): It is well known that not all
cases respond to the Qsw lasers. This is possibly as the lesion can have
varying colors, which logically will respond to various wavelengths.
Thus a combination of QS Nd:YAG-1,064nm,QS alexandrite 755nm and
QS Nd:YAG 532nmlasers were used in accordance with the test patch
results. Lasermodality was switched following repeated test patches if
there was no or no sustained improvement. Though most of the patients
had 90% improvement compared to baseline photographs, the results
were dependent on the color. Grey lesions and those on the forehead/
temple were most resistant.
Literature Review
The analysis of the results of laser in nevus of Ota (Table 3.7), give some
sobering facts of the actual efficacy which are important to under stand
before the treatment is attempted.
1. The success rate specially in pigmented skin is rarely 100%. The average
results are 50% and this is also after multiple sittings.
2. Various combinations have been tried which is proof of the less reliability
of monotherapy with a Q-switched laser. Conversely combination with
fractional laser may look impressive in clinical reports, but the actual
results may not be superior to monotherapy.
3. It is important to focus on the color of the lesion that predicts the
response. A study by Ueda et al. found that the 22 brown lesion attained
an excellent (95100%) or good (7595%) cosmetic results (3 treatments).
Of the other 42 brown-violet lesions, only 25 of the 29 had good or
excellent results after four treatments, of the 81 violet-blue lesions, 54
of the 65 had good or excellent results after four treatments while the six
blue-green lesions, had the poorest response.
This concept was again proved by a study by Fulton et al. where in only
20% of patients, was the QS-1,064nm found to be efficacious. Also the
number of treatments required varied significantly according to lesional
color and site: grey lesions and those on the forehead/temple were most
resistant.
4. Thus before we embark on the laser therapy, various aspects must be
considered. Reporting of results in studies do not reflect actual patient
improvements as they employ subjective methods of assessment, which
invariably do not reflect actual improvement.

Table 3.7 Overview of results with various lasers used for nevus of Ota
Author
Clearing (%)
Laser used
Conclusions
Kono et al.
2003
100
QS RL
Early QSRL treatment of nevus of Ota

in children results in fewer required
sessions and complications, but
recurrence is still a concern
Kono et al.
2001
75
QS RL
Side-effects are pigmentary changes;

mainly hypopigmentation that may
be permanent. Recurrence is rare but
important in childhood cases
Yang et al.
50
QS RL
QSRL treatment is efcacious and safe,

without scarring. However, transient
pigmentary changes, especially
hyperpigmentation, are common
Suh et al.
7% patients with QS Alex

improvement
QS Alex is safe and effective, with

better results after repeated treatments.
Histologic evidence of laser-induced
thermal damage of melanocytes
demonstrated
Wang et al.
Variable
QS Alex
QS Alex treatment is safe and

effective with few cases of transient
hypopigmentation as the main sideeffect. Increased treatment sessions
yielded better results
Kang et al.
75%
QS Alex
QS Alex treatment is safe and effective

but limited by hyperpigmentation in
darker skin types, delay in therapeutic
effect, and lack of complete clearing.
Histologic evidence of laser-induced
selective destruction of melanocytes is
demonstrated
Chan et al.
Alex: 1026
YAG: 3562
QS Alex
QS Nd:YAG
QS Nd:YAG is superior to QS Alex in

subjective assessments of lightening, but
no statistical difference in efcacy was
determined
Kar HK et al.
2011
8% had
excellent
efficacy
QS Nd:YAG
Sardana K
25%
QS Nd:YAG
In our experience the efficacy is not as

marked as with Western skin type
Sethuraman G
>50% pigment
clearance
QS Nd:YAG
Though melanin index showed a

improvement, clinical results were not
as dramatic as revealed by the percentile
improvement
Pearls/Pitfalls
1. As PIH is a common complication a low dose of 2.5 j/cm2 can be tried
which has been shown to reduce the side effects.
2. Hori nevus is difficult to treat and the results are inferior to that of N of
Ota.
3. The use of topical fucidic acid plus betamethasone valerate cream for
2 weeks after the session has been shown to reduce the pigmentation
(Uaboonkul T). But excessive use can lead to hypopigmentation.
4. In pigmented skin, conservative fluencies are advisable as occasionally
melasma like lesions may develop consequent to laser therapy (Lee WJ).
Bibliography
1. Chan HH, Ying SY, Ho WS, Kono T, King WW. An in vivo trial comparing the
Q-switched 1064 nm Nd:YAG lasers in the treatment of nevus of Ota. Dermatol
Surg. 2000;26(10):919-22.
2. Felton SJ, Al-Niaimi F, Ferguson JE, Madan V. Our perspective of the treatment
of naevus of Ota with 1,064, 755 and 532 nm wavelength lasers. Lasers Med Sci;
2013.
3. Kang W, Lee E, Choi GS. Treatment of Otas nevus by Q-switched alexandrite
laser: therapeutic outcome in relation to clinical and histopathological ndings.
Eur J Dermatol. 1999;9(8):639-43.
4. Kar HK, Gupta L. 1064 nm Q switched Nd:YAG laser treatment of nevus of Ota: An
Indian open label prospective study of 50 patients. Indian J Dermatol Venereol
Leprol. 2011;77(5):565-70.
5. Kono T, Chan HH, Ercocen AR, et al. Use of Q-switched ruby laser in the treatment
of nevus of Ota in different age groups. Lasers Surg Med. 2003;32(5):391-5.
6. Kono T, Nozaki M, Chan HH, Mikashima Y. A retrospective study looking at the
long-term complications of Q-switched ruby laser in the treatment of nevus of
Ota. Lasers Surg Med. 2001;29(2):156-9.
7. Lee WJ, Kim YJ, Noh TK, Chang SE. Formation of new melasma lesions in the
periorbital area following high-fluence, 1064-nm, Q-switched Nd/YAG laser. J
Cosmet Laser Ther. 2013;15(3):163-5.
8. Manuskiatte W, Sivayathorn A, Leelaudomlipi P, Fitzpatrick RE. Treatment of
acquired bilateral nevua of Ota-like maculess (Horis nevus) using a combination
of scanned carbon dioxide laser followed by Q-switched ruby laser. J Am Acad
Dermatol. 2003;48(4):584-91.
9. Moody MN, Landau JM, Vergilis-Kalner IJ, Goldberg LH, Marquez D, Friedman
PM. 1,064-nm Q-switched neodymium-doped yttrium aluminum garnet laser
and 1,550 nm fractionated erbium-doped fiber laser for the treatment of nevus of
Ota in Fitzpatrick skin type IV. Dermatol Surg. 2011;37(8):1163-7.
10. Sardana K, Chugh S, Garg V. Are Q-switched lasers for Nevus of Ota really effective
in pigmented skin? Indian J Dermatol Venereol Leprol. 2012;78(2):187-9.
11. Sethuraman G, Sharma VK, Sreenivas V. Melanin index in assessing the treatment
efficacy of 1064 nm Q Switched Nd-Yag laser in nevus of Ota. J Cutan Aesthet
Surg. 2013;6(4):189-93.
12. Uaboonkul T, Nakakes A, Ayuthaya PK. A randomized control study of the
prevention of hyperpigmentation post Q-switched Nd:YAG laser treatment of
Horinevus using topical fucidic acid plus betamethasone valerate cream versus
fucidic acid cream. J Cosmet Laser Ther. 2012;14(3):145-9.

13. Wang HW, Liu YH, Zhang GK, et al. Analysis of 602 Chinese cases of nevus of
Ota and the treatment results treated by Q-switched alexandrite laser. Dermatol
Surg. 2007;33(4):455-60.
Acquired Bilateral Nevus of Ota-like Macules

(ABNOM or Horis macules)
Horis macules are dermal hyperpigmentations commonly seen in Asian
patients that affect approximately 0.8% of the population. Horis macules
present as bilateral blue-gray macules typically located over the malar region
in a symmetrical pattern. The lateral temples, alae nasi, eyelids, and foreheads
can also be involved. Histologically, dermal melanocytes are dispersed in the
papillary and middle part of the dermis.
In contrast to nevus of Ota, the pigmentation of Horis macules is acquired,
has a late onset in adult-hood, and does not affect the mucosa. Melasma and
Horis macules can coexist in some patients.
Lasers Used
Like nevus of Ota, QS lasers have been shown to be effective for treatment of
Horis macules. Combined laser therapy has also been found to be effective.
One study indicated that a QS 532-nm Nd:YAG laser used in conjunction with
a QS 1,064 nm Nd:YAG laser can achieve better results than laser on its own.
Another option is to use an ablative laser to rst remove the epidermis and to
allow better penetration of the QS ruby laser.
Bibliography
1. Ee HL, Goh CL, Khoo LS, Chan ES, Ang P. Treatment of acquired bilateral nevus
of ota-like macules (Horis nevus) with a combination of the 532 nm Q-Switched
Nd:YAG laser followed by the 1,064 nm Q-switched Nd:YAG is more effective:
prospective study. Dermatol Surg. 2006;32:34-40.
2. Manuskiatti W, Sivayathorn A, Leelaudomlipi P, Fitzpatrick RE. Treatment of
acquired bilateral nevus of Ota-like mac-ules (Horis nevus) using a combination
of scanned carbon dioxide laser followed by Q-switched ruby laser. J Am Acad
Dermatol. 2003;48:584-91.
Congenital Dermal Melanocytosis

Mongolian spots are congenital and confluent hyperpigmented areas that
are usually grayish blue in color. They are found most frequently in the sacral
region in infants and typically disappear during childhood. Occasionally,
they persist to adulthood.
Lasers
Q-switched alexandrite laser has been used though extrasacral lesions are
more resistant to therapy. In adults more frequent irradiation, longer intervals
between treatment sessions, and use of bleaching creams is required in the

treatment of persistent sacralMongolianspots in adults.
Bibliography
1. Kagami S, Asahina A, Uwajima Y, Miyamoto A, Yamada D, Shibata S, et al.
Treatment of persistent Mongolian spots with Q-switched alexandrite laser.
Lasers Med Sci. 2012;27(6):1229-32.
2. Shirakawa M, Ozawa T, Ohasi N, Ishii M, Harada T. Comparison of regional
efficacy and complications in the treatment of aberrant Mongolian spots with
the Q-switched ruby laser. J Cosmet Laser Ther. 2010;12(3):138-42.
Infraorbital Hyperpigmentation (dark circles)

This may result from a variety of causes, including dermal melanin deposition,
post-inammatory hyperpigmentation from atopic or allergic contact
dermatitis, prominent supercial blood vessels, and shadowing from skin
laxity and infraorbital swelling.
Thus the therapy will require correction of the pigmentation, the skin
laxity and the vascular accentuation.
Lasers Used
Lasers primarily work on the pigmentation,which in our experience responds
as well to topical creams.
Qsw Lasers
The QSRL has been reported to effectively treat infraorbital hyperpigmentation
due to deposition of dermal melanin.The other Q-switched lasers, especially
the Q-switched alexandrite laser, are also effective treatments in studies.
Ablative Lasers
Improvement of this condition has also been reported following carbon
dioxide laser resurfacing and the combination of carbon dioxide laser
followed by Q-switched alexandrite laser.
Fractional Lasers YSGG 2,790 nm

The 2,790 nm Er:YSGG wavelength has a lower water absorption coefficient
than the 2,940 nm. Er:YAG, but a higher coefficient than the 10,600 nm CO2
laser. This allows ablative resurfacing with mild thermal coagulation, which
may increase clinical efficacy while reducing patient downtime. Two studies
have been done with this laser, and we feel that the fractional Er:YAG would
be a better option as this laser would penetrate even lesser than the YSSG
laser, thus would be safer.
Other Options
Blepharoplasty may be indicated when infraorbital darkening is due to
excessive skin laxity. Soft tissue augmentation with llers may be benecial if
there is shadowing due to a hollow in the tear trough.
Pearls/Pitfalls
A combination therapy will help to target the various causes of infraorbital
darkening.
Probably the Thulium laser would be the safest of all the fractional lasers,
though it has not been formally tried.
Bibliography
1. Ma G, Lin XX, Hu XJ, Jin YB, Chen H. Treatment of venous infraorbital dark
circles using a long-pulsed 1,064-nm neodymium-doped yttrium aluminum
garnet laser. Dermatol Surg. 2012;38(8):1277-82.
2. Park KY, Oh IY, Moon NJ, Seo SJ. Treatment of infraorbital dark circles in atopic
dermatitis with a 2790-nm erbium: yttrium scandium gallium garnet laser: a
pilot study. J Cosmet Laser Ther. 2013;15(2):102-6.
3. Walgrave SE, Kist DA, Noyaner-Turley A, Zelickson BD. Minimally ablative
resurfacing with the confluent 2,790 nm erbium:YSGG laser: a pilot study on
safety and efficacy. Lasers Surg Med. 2012;44(2):103-11.
Drug-induced Hyperpigmentation
Minocycline, doxycycline, amiodarone, and azidothymidine (AZT, zidovudine) can cause hyperpigmentation of the skin that appears as gray-brown
to brown. Despite the fact that the Q-switched Nd:YAG (1,064 nm) laser
theoretically has a greater penetration depth, the present data does not allow
any comparisons to be made between the various lasers.
Minocycline Pigmentation
The maximum experience regarding minocycline-induced hyperpigmen
tation is with the Q-switched ruby laser though in India primarily the
Q-switched Nd:YAG laser at a wavelength of 1,064 nm is used and requires
upto 8 sesions for complete removal.
Type I minocycline-induced hyperpigmentation is responsive to
Q-switched Nd:YAG laser (1,064 nm). This is as the pigment is in the dermis.
In cases of type II minocycline-induced hyperpigmentation (i.e., generalized hyperpigmentation along the basal membrane zone), the Q-switched
ruby laser is more effective because the shorter wavelength (694 nm) is better
absorbed by the pigment particle in the epidermis.
Pearls/Pitfalls
Caution is advised when treating drug-induced dyschromia with
Q-switched lasers, even despite the therpeutic successes noted in literature.
Patients who take or have taken gold medication may experience mottled
hyperpigmentation (laser-induced chrysiasis) after treatment with a
Q-switched laser, regardless of the indication for laser therapy.
The skin type and extent of tanning pose constraints on the efcacy of the
pigment laser.
Level of Difficulty
Time consuming and prolonged.
Bibliography
1. Argenyi ZB, Finelli L, Bergfeld WF, et al. Minocyclinerelated cutaneous
hyperpigmentation as demonstrated by light microscopy, electron microscopy
and X-ray energy spectroscopy. J Cutan Pathol. 1987;14:17680.

PATIENT SELECTION
For all patients an appropriate patient expectation is crucial. As a thumb rule,
epidermal disorders have a good response while dermal disorders do not
respond consistently, specially in pigmented skin.
Tattoo: The ideal patient for tattoo removal is an untanned patient with type I
or II skin and a dark-blue or black tattoo. The older the tattoo, the better is the
response to laser treatment as macrophages are already present in the skin
and probably partially phagocytoses the foreign pigment particles. But this is
controversial as some authors believe that older the tattoo, less the response
as the depth and size of the tattoo has been altered .
Other lesions: A low contrast lesion has a better response. Thus conditions
like melasma or dermal disorders in Indian skin have mixed results. Similarly
lentigines are easy to treat, while postinflammatory hyperpigmentation
(PIH) and nevi of Ota and Ito are challenging.
Sunscreens: It is important to stress that regular sunscreen use will aid in a
durable result (especially in the case of solar lentigines).
In patients with darker skin types, it would be a good practice to use
hydroquinone 4% or non-HQ based creams and ceasing treatment 1 week
prior to laser therapy. An SPF beyond 35 is rarely of any advantage in
pigmented skin.
PREOPERATIVE STEPS
1. Biopsy: Apart from medicolegal requirements it is useful in cases
like melanocytic nevi and tattoo where the treatment can be planned
according to the depth of the pathology.
2. Anesthesia: Preoperatively, EMLA cream (eutectic mixture of lidocaine
2.5% and prilocaine 2.5%) is applied to both sides of the face 1 hour
before laser treatment. Another option is to use lidocaine, and tetracaine
(a typical concentration is 7% of each). A thick layer leads to anesthesia
within 45 minutes. Penetration of the topical anesthetic can be enhanced
by putting the medication under occlusion or applying warm towels
over the area. Caution should be exercised if the area is large as topical
anesthetics can produce toxicity. Anesthetic cream should always be
completely removed prior to treatment.
Ice is another option and a simple option is to use ice cubes wrapped
in gauze. This should precede the laser treatment with caution to ensure
that no water is left behind.
For dermal pigmented lesions on the face, such as nevus of Ota, we
sometimes use infiltration anesthetisia.
3. Baseline photograph.
4. Eye safety: Eye safety is paramount when using lasers. Wavelengthspecific protective glasses or goggles must be worn by the patient,
provider, and staff at all times during a laser procedure. If the area to
be treated is on the eyelid or near the orbit, specially in the case of the
deeply penetrating Nd:YAG 1064 nm laser, internal metal eye shields
should be placed for the patient.
5. Use the Kirby Desai score to appropriately guide patients regarding the
realistic number of sessions required (Tattoo removal).
INTRAOPERATIVE
1. The area should be cleaned with normal saline, and eye shields applied.
2. A test shot should be given at a low frequency . Test spots should be
evaluated at 46 weeks for hypo- or hyperpigmentation and efficacy.
3. The handpiece should be kept perpendicular to the target area.
4. A clear hydrogel may be placed over the target to avoid tissue splatter
(tattoo).
5. Treatment sessions should be spaced at least 68 weeks apart.
End Points
Epidermal Disorders
The end points of the 532 and 1,064 nm Q-switched Nd:YAG lasers is
epidermal whitening and minimal epidermal petechiae, respectively. The
immediate whitening keeps additional light from entering the skin due to
reflection. Pulse stacking should be avoided as this may increase the risk of
scarring and unnecessary thermal injury. For milliseconds lasers or IPL the
end point is slight lesional darkening.
Dermal Disorders
Optimal endpoint using a Q-switched laser is uniform but faint immediate
whitening without epidermal disruption. If significant energy is absorbed
by a pigmented lesion, pinpoint bleeding may occur, as occasionally occurs
with tattoos. Performing 24 treatments of a tattoo all in one day (waiting for
the immediate whitening to fade between treatments) seems to increase the
degree of fading achieved in one visit, but we do not employ this method in
our setting.
POSTOPERATIVE
1. Postoperatively, the lasered areas is cleansed with normal saline and
mupirocin ointment is applied twice a day for 1 week.
2. The patients should be instructed to keep away from the sun and to
avoid the use of any cosmetics for 1 week.
3. The use of a low potency-topical corticosteroids for 34 days to prevent

any pigment alteration due to inflammation from the treatment is a
useful adjunct itself. Also a sunscreen (physical block) and or non HQ/
Tretinoin cream can be initiated after 7 days up to 21 days (MelaglowTM)
PEARLS/PITFALLS
1. It is a good habit to clean the cone of the Qsw lasers with spirit and check
the level of water (in some Qsw lasers) frequently.
2. Use the optimal laser goggles specially when changing the wavelength
as in a muticolored tattoos. A optical density (OD) of at least 6 is ideal.
If the patient goggles obstruct the treatment area in the periorbital area,
an anodized external metal eye cup can be used to protect the patients
eyes.
3. As a thumb rule, it is better with pigmented lasers to increase the
diameter of the probe than energy to achieve more depth.
4. For tattoo, a polka dot therapy is adopted where the first pass is spaced
out. This is followed by a pass that covers the space in between. This
minimises thermal damage.
ATLAS
Fig. 1: A case of segmental lentiginosis. Plan: Qsw Nd:YAG (532 nm, 2 Hz 2.5 J/cm2).
Single spot technique
Fig. 2: Immediate postoperative view using the Protocadamus Qsw Nd:YAG. Note the
end point of whitening and slight bleeding
Fig. 3: A multicolored professional tattoo. Plan: Black tattoo:Qsw Nd:YAG 1,064 nm

and red tattoo with Qsw Nd:YAG 532 nm
Fig. 4: Professional black tattoo treated with Qsw Nd:YAG (1,064 nm; 5.1 J/cm2)
Fig. 5: Intraoperative photograph of a nevus spilus case treated with Qsw Nd:YAG
(1,064 nm). The background pigmentation rarely responds consistently to any laser
and this should be communicated to the patient
Fig. 6: Immediate postoperative photograph of a case of lentigines treated with the

Qsw Nd:YAG (532 nm; 2.5 J/cm2). End point is whitening with erythema which is a
variable patient-dependent feature
Fig. 7: A female patient with segmental lentigines
Fig. 8: Same patient after 4 sessions with a Qsw Nd:YAG (523 nm, 3 Hz)
Fig. 9: After 5 sessions and at 6 months follow-up, there is marked improvement of

the lesion
Fig. 10 : Nevus of Ota in a female patient. Plan: Treat with Qsw Nd:YAG (1,064 nm)
Fig. 11: After 7 sessions there is a partial diminution in the lesion. A large probe size
34 mm is ideal for treating dermal disorders over a large area
Fig. 12: A simple black amateur tattoo. Plan: Qsw Nd:YAG 1,064 nm. Such tattoos
respond to most Qsw laser
Fig. 13: Complete removal after 3 sessions
Fig. 14 : A black amateur tattoo treated by Modified Tattoo Removal Technique (Up
CO2 followed by Qsw Nd:YAG)
Fig. 15 : After 3 sessions there is almost complete removal of tattoo
Fig. 16: A black amateur tattoo treated with Er:YAG followed by Qsw Nd:YAG
Fig. 17: The center of the tattoo is ablated using Er:YAG set at 2 J/cm2 2 Hz to ablate
the epidermis. Note the whitening of the epidermis which is a characteristic transient
feature Er:YAG
Fig. 18: The ablation of the epidermis reveals the visible tattoo pigment and is then
treated with Qsw Nd:YAG 1,064 nm. The rest of the tattoo is treated with Qsw Nd:YAG
lasers
Fig. 19: The split lesion view reveals a marked improvement in the combined laser
treatment area
(Sardana K, Garg VK, Bansal S, Goel K. A promising split-lesion technique for rapid
tattoo removal using a novel sequential approach of a single sitting of pulsed CO2
followed by Q-switched Nd:YAG laser (1,064 nm). J Cosmet Dermatol. 2013;12(4):296305)
CHAPTER
Fractional Photothermolysis
Kabir Sardana, Payal Chakravarty, Anuj Tenani
OVERVIEW
This technology has its genesis in the attempt to overcome the disadvantages
of conventional ablative and nonablative laser therapies. The basic concepts
for these studies were introduced in 2003 and reported in full during
2005 (Huzaira M, et al.). Manstein and colleagues introduced fractional
photothermolysis (FP) in 2004 with their original prototype FP device. The
initial studies were restricted to the forearm-skin and periorbital rhytides
but the same principles apply to facial skin where the commonest indication
is acne scarring (Tannous Z, et al.). The chromophore for fractional
photothermolysis is tissue water, with targets being epidermal keratinocytes,
dermal collagen, and dermal vascular structures. Unlike bulk heating of
ablative devices, fractional photothermolysis capitalizes on untreated tissue
to accelerate wound healing. This action of the laser, where only a fraction of
the epidermis is damaged, is the genesis of the term fractional laser.
SCIENTIFIC LOGIC
The scientific concept underlying FP involves the application of microscopic
beams of pixelated light, which induce small, focal zones of tissue injury.
Because the pixelated zones of treatment spare surrounding normal tissue, reepithelialization occurs at a significantly faster pace. The tissue injury created
with FP stimulates the process of collagen remodeling and deposition and
promotes elastic tissue formation. These molecular changes are postulated
to be responsible for the clinical improvements seen with FP. A comparison
of various fractional laser technological systems is given in Table 4.1 and is
depicted in the Figure 4.1. Nonablative lasers are discussed in a separate
chapter.
Arrays of microscopic columns of thermal injury (MTZ) (Fig. 4.1)
surrounded by intact tissue is the hallmark of fractional photothermolysis.
The depth of the MTZ may vary and depends on various factors including
wavelength, dose, pulse duration, density and temperature of the target
Fractional Photothermolysis 173

Table 4.1 Comparison of the nonablative and ablative fractional lasers with
traditional ablative lasers (Narukar et al.)
Nonablative
fractional (NAFR)
lasers
Ablative fractional
(AFR) lasers
Ablative lasers
Wavelength
1540 nm, 1550 nm
2940 nm, 10,600 nm
2940 nm, 10,600 nm
Type
Fractional, nonablative
Fractional, ablative
100% coverage ablative/

pseudofractional, ablative
S. corneum
damage
No
Yes
Yes
Downtime
None
48 hours
47 days
Avoid Sun
13 days
5 days
2.54 weeks
Depth
1.4 mm
1.6 mm
1 mm/pass (laser dependent)
Dermal damage
No
Yes
Yes
No. of sitting
35
PIH
No
No
Yes
Fig. 4.1: A comparison of various ablative and nonablative lasers. a = zone of

ablation, k = zone of coagulation. Ablative lasers (total ablation of epidermis),
nonablative lasers (subsurface effect, epidermis is intact), NAFR (columns are formed
with intact stratum corneum). AFR (columns with loss of stratum corneum and zone
of coagulation)
Abbreviations: MTZ, Microthermal zone; NAFR, Nonablative fractional laser; AFR,
Ablative fractional laser
tissue. The shape of such MTZs is either an inverted cone or a tapered column
extending into the dermis. The histological effect is that of a microscopic
epidermal necrotic debris (MEND) which shuttles out within 24 hours
followed by collagen regeneration which may take months. The rapid tissuehealing is because a fraction of the skin is damaged and thus ensures rapid
healing, which forms the basis of fractional lasers (Fig. 4.2).
FRACTIONAL VERSUS SELECTIVE PHOTOTHERMOLYSIS

Fractional photothermolysis (FP) is distinct and yet similar to the wellknown process of selective photothermolysis (SP) originally described over
20 years ago (Manstein D, et al) (Table 4.2). Both SP and FP cause small,
spatially limited zones of photothermal effects within tissue due to local
energy deposition. Widespread clinical use of SP for decades has shown
that this type of injury is very well tolerated; the same is true for FP. In any
photothermal process, including SP and FP, distribution of thermal excitation
is proportional to the product of the local optical energy density times the
local optical absorption coefficient. While SP relies on selective absorption
of a largely uniform optical field by pigmented target structures, FP relies on
optical foci within a largely uniform medium. It should be noted that SP and
FP are conceptual descriptions of idealized situations (Table 4.2). In practice,
neither the medium nor the optical field is ever completely homogenous.
Fig. 4.2: Diagram depicting the regeneration of damaged tissues consequent to

fractional laser therapy (Asclepion Laser Technologies, GmbH)
Table 4.2 Difference between SP and FP
Characteristic
Selective
photothermolysis (SP)
Fractional
photothermolysis (FP)
Optical field in medium
Homogeneous
Focused beam
Optical properties of medium
Local absorbers
Homogeneous
Confined thermal damage
Target chromophore
Optical focus regions
CLASSIFICATION OF FRACTIONAL TECHNOLOGY

There are broadly two types of fractional lasers: 1) nonablative fractional
laser, and 2) ablative fractional lasers. A list of some of the leading fractional
laser manufacturers is given in Table 4.3 for quick reference.
Nonablative Fractional Resurfacing (NAFR)

True NAFR requires three criteria: (a) nonablative mode of tissue coagulation,
with the stratum corneum remaining intact and the tissue not being vaporized,
(b) creation of multiple microthermal zones surrounded by islands of viable
tissue, and (c) resurfacing with extrusion and replacement of damaged
tissue, with re-epithelialization within 24 hours (Figs 4.1 and 4.2). The major
conundrum is to balance the minimal clinical effects, which are usually seen
with traditional nonablative modalities resulting in disappointing clinical
results, and blistering which produces an ablative like response.
Systems and Devices

The basic concept is to use a wavelength with optimal mid-dermal
penetration. These include the 1,320, 1,410, and 1,440 nm Nd:YAG laser, the
1,450 nm diode laser, and the 1,535, 1,540, and 1,550 nm ytterbium:erbiumphosphate glass (also known as erbium:glass or Er:Glass) laser.
1. 1,320-nm Nd:YAG Laser

It typically leads to an epidermal heating of 4050C accompanied by a
temperature elevation within the dermis up to 70C with a uence of 1218 J/
cm2 (1719 J/cm2 CoolTouch3, CoolTouch Corp., Roseville, Calif. USA). It has
a fixed spot size of 10 mm and gives six stacked pulses at a duration of 50 ms.
2. 1,410-nm System (Fraxel re:ne)

This has the facility of a variable spot size and a continuous motion scanner
which enables MTZs of 500 m in depth.
3. 1,440-nm Nd:YAG Laser (Afrm, Cynosure, Westford, Mass. USA)

This uses a microarray of lenses and delivers a 10-mm fractional beam. It also
has a a spot size of 15 mm (470 microbeams), with a microbeam density of
320 spots per cm2.
4. 1,450-nm Diode Laser

It provides four stacked pulses (210 ms), interspersed with ve cryogen
applications to ensure cooling. The 4 or 6-mm spot size provides uences
ranging from 9 to 14 J/cm2. The usage of energies above 12 mJ/cm2 has
been reported to lead to an increased production of collagen type III but

not collagen type I or elastic bers (Smoothbeam, Candela, Wayland, Mass,
USA). The lower penetration wavelength is especially suitable for patients
with thinner skin (400 m with 1,320 nm vs 200 m with 1,450 nm).
5. 1,540-nm Er:Glass Laser (Lux1540, Palomar Medical Technologies, Inc.)

This is a laser that has been widely used by us and can be used in a normal or
single pulse mode. The pulses are delivered with a frequency of up to 3 Hz.
The system is equipped with a 4-mm spot size to apply typical uences of
810 J/cm2 up to 70 mJ throughout a chilled sapphire window. It has two tip
size 15 mm for superficial indications like melasma and a 10 mm tip used for
deeper pathologies like acne scars (Fig. 4.3).
6. 1,550-nm Erbium Laser (Fraxel, Reliant Technology)

This was the rst device to adopt the concept of fractional photothermolysis.
This has been improved upon by the 1,550-nm Er:Glass laser (Mosaic,
Lutronic Corporation, Gyeonggi, Korea), which has a large energy range
up to 120 mJ. In addition, the system allows for the application of the laser
energy in different modes. The so-called static mode, also known as stamp
mode, delivers, with the appropriate tips, light to treatment areas of varying
sizes (6 6, 8 8, 5 10 and 10 10 mm). The system has the advantage of
using nonlinear, nonsequential microbeam delivery technology (Controlled
Fig. 4.3: The Star Lux-500 laser system with a Lux 1,540-nm fractional 10 mm
handpiece (Palomar Medical Technologies, Burlington, MA)
Chaos Technology). In combination with variable microbeam delivery

and a skin sensing feature within the tips, a decrease of the likelihood of
postinammatory hyperpigmentation in darker skin types is reported
(Laubach et al.).
More recently, a CO2 Laser equipped with a scanner has been used for
nonablative fractional treatments. In this, a spot density of 8 8 spots/cm2
(64 MTZ/cm2) was used. The spot size was set to 500 m, laser power adjusted
to 12 W, and pulse duration set to 35 ms (3660 mJ). On histology slides,
the microthermal treatment zone was characterized mainly by absence of
ablation and display of very supercial epidermal coagulation immediately
after exposure, leading to average increases in skin density of 40.2% without
any signs of postinammatory hyperpigmentation.
Ablative Fractional Resurfacing (AFR)

There are two types of AFR, the Fractional Er:YAG (2940 nm), which utilizes
traditional ablative wavelengths, such as 2940 nm (Dermablate, Profractional
2940 Laser, Lux 2940, Pixel 2940 Laser and Protocadmus) (Figs 4.4 and
4.5) and the Fractional CO2 (10,600 nm) which utilizes the standard CO2
wavelength (Active FX, Fraxel Repair, mixTo, Protocadmus) (Figs 4.6 and 4.7).
The Er:yttrium-scandium-gallium-garnet (YSSG) (2,790 nm) laser is also
used for AFR, though the experience with that system is limited (Table 4.3).
The rationale for ablative fractional devices is to reduce the number
of treatments as compared with nonablative fractional devices and still
maintain greater safety than traditional ablative modalities. The depth of the
MTZ is primarily dependent on pulse energy and may extend into the deep
reticular dermis. The resulting tapered cavity is lined by a thin layer of eschar
and surrounded by a cuff of thermal denaturation, which is sufficient to
destroy cells and coagulate collagen. Ablative FP results in immediate tissue
loss due to the physical removal of portions of the skin by vaporization, and
the physical integrity and barrier function of the skin is locally compromised.
Systems and Devices

Fractional Carbon Dioxide Lasers
The rst two microfractional systems were the Re:Pair (Solta Medical, Inc.,
Hayward, Calif., USA) and the Lumenis DeepFx (Santa Clara, Calif. USA)
1. Solta device: This uses a continuous paint-brush motion to apply
the laser microbeams to the tissue, whereas the Lumenis device
employs a stamped scanning technology. The Solta Re:Pair uses a
microprocessor-controlled handpiece to deliver a laser beam with a
penetration depth of 3001,600 mm, which is determined by the pulse
energy, up to a maximum of 70 mJ. Treatment densities (or coverage)
may be adjusted from 5% to 50% by performing multiple passes and
choosing higher treatment densities, which are chosen based on the
severity of photodamage or presence of scarring.
Fig. 4.4: Dermablate (Fractional Er:YAG) (Asclepion Laser Technologies, GmbH)
Fig 4.5: Protocadamus laser system
2. Lumenis: The company introduced a macrofractional handpiece

(ActiveFX, Lumenis) as an attachment to their CO2 resurfacing laser
in 2006: The macrofractional handpiece scans patterns with a 1.3mm spot size, at treatment densities providing 5090% of surface area
coverage. Ablation is limited to the epidermis with some coagulation
of the papillary dermis, producing a supercial laser peel that heals
in 34 days. In 2007, a microfractional attachment (DeepFX) was
introduced. This microfractional handpiece fractionates the laser beam
Fig. 4.6: SuperPulse CO2 (Lumenis)
Fig. 4.7: UltraPulse CO2 (Lumenis)
Wavelength and
pulse duration
1,320/1,440 nm
Nd:YAG
1,550 nm
Nonablative
True fractional
1,410 nm
Er:Glass
1,550/1927 nm
Er:Glass/thullium
1,540 nm
Nonablative
True fractional
Er:Glass
1,540 nm
Nonablative
True fractional
Er:Glass
1,540 nm
Nonablative
True fractional
Er:Glass
1,545 nm
Er:Glass
Affirm
(Cynosure)
Fraxel re:store
(Solta)
Fraxel re:ne
(Solta)
Fraxel
re:store
DUAL
Lux
(Palomar)
Lutronic
(Mosaic)
Matisse
(Quanta)
Protocadmus
Stamp
Stamp
Scanned
stamping
Stamp
Rolling
Rolling
Scan
Stamping
Mode
100 m/
30150 m
220 m/
Up to 1000 m
125200 m/
125850 m
135600 m
100 m/
5001200 m
100 m/
200300 m
NA
Energy (mJ/MTZ)
NA
520
540
70100
470
520
520
840
812
Nonablative fractional lasers
Diameter/depth
Table 4.3 A summary of fractional lasers with their specifications*
Laser
Company
NA
1000
mb/cm2
100500
mb/cm2
100320
mb/cm2
250
mb/cm2
1000
mb/cm2
Density/(cm2)
NA
NA
NA
1025
1220
1030
Contd...
Fractional coverage of skin surface at

end of one session (%)
Wavelength
1,550 nm
Er:Glass
2,940 nm
(1001000 s)
2,940 nm
(0.25.0 ms)
2,940 nm
2,940 nm
(12 ms)
10,600 nm
(<1 ms)
Laser
Company
Sellas
MCL 30
MCL 31
Ascepelion
(variable pulse
duration)
Lux
2940 (Palomar)
Profractional
(Sciton)
Pixel
(Alma)
Active FX
Lumenis
(1.3-mm spot
size)
Deep Fx (Spot
Size=0.12 mm)
SCAAR Fx
Contd...
Scanned
paint
brush
Scanned
Stamp
Scanned
Stamp
Scanned
stamping
Mode
1300
Energy (m J/MTZ)
540
70100
840
812
120 m/
1501600 m
120 m/
4000 m
1300 m/
10300 m
60 W
Ablative fractional lasers CO2
220 m/
Up to 1500 m
125 m200 m/
125850 m
100 m/
5001200 m
100 m/
200300 m
Ablative fractional lasers Er:YAG
Size:
3121000 m
Diameter/Depth
100500 mb/cm2
100320 mb/cm2
250 mb/cm2
1000 mb/cm2
Density/(cm2 )
3060
NA
1025
1220
1030
Contd...

0.3-0.5 ms
10,600 nm
(0.153 ms)
(0.81.8 ms)
10,600 nm
(200s-2.0ms)
10,600 nm
10,600nm
(2.516 ms)
0.22.0 ms
150 ms
Variable
Variable
Accupulse
(Superpulse)
Fraxel re:pair
(Solta)
Smartxide Dot
(Deka)
Youlaser CO2
(Quanta)
Quadralase
(Candela)
Mixto SX
(Lasering )
Multipulse
(Ascepelion)
ProFrax C2
Protocadmus
eCO2
(Lutronic)
Pearl
(Cutera)
Scanned
Stamping
dynamic
Scanned
(four
quadrants)
paint
brush
motion
paint
brush
1201000 m/
2,500 m
510 m
Up to 5000 m/
350 m
500800 m
180 m/200 m
Ablation depth
30750 m
350 m/
500800 m
140 m/1600 m
0.12 mm and
1.3 mm/1mm
Diameter/Depth
30 W
30
0.530 W
60 W
30 W
30 W
40 W
40 W
Energy (mJ/MTZ)
3090 mJ
225 mJ
Density/(cm2 )
300/1,500
60320 mJ/
microspots
Ablative Fractional Lasers Fractional YSGG laser
Scanned
conventional
IOTS
(paintbrush)
continuous
motion
Mode
530%
5% to 50%

*As laser treatment depends on various parameters and novel devices are added, it is advisable to refer to company manuals for device specific settings to optimize depth
and results
Wavelength and
pulse duration
Laser
Company
Contd...
to a diameter of 0.12 mm and uses a stamping-style microscanning

method. The handpiece produces multiple different geometric scan
shapes, and treatment densities can be varied from 5% to 50%. The pulse
energy determines the depth of tissue injury, with a maximum of 70 mJ
providing tissue penetration up to 1 mm.
3. The DEKA system (SmartXide DOT, Calenzano, Italy) is a low-power
(30 W) CO2 laser used with a scanning handpiece. The scanned
microbeam measures up to 350 m and the pulse duration varies from
200 to 2,000 ms. The longer pulse durations, used with this system,
produce larger zones of coagulation around the ablated channels of
tissue.
Fractional Erbium:YAG Lasers

1. Palomars fractional Er:YAG: This has the multiple interchangeable
optical tips that provide various densities (1701,000 microbeams/cm2)
of focused miocrobeam arrays (each ~75150 mm in diameter) with up
to 12 mJ/microbeam of energy. The density of microbeams is xed for
each optical tip, but the total density of microbeams delivered will vary
depending on the number of laser passes. This laser ablates tissue to
depths of 1,000 m without coagulation when used with a pulse width
of 0.25 ms, and produces zones of coagulation up to ~70 m with 5-ms
pulse durations.
Another attachment produces a 6-mm spot size with a directional or
groove pattern of injury, with each groove measuring 100200 m in
width and 350 m in depth spaced at 350-m intervals. The treatment
density is increased by performing additional laser passes with varied
orientations of the linear pattern.
2. Sciton, Inc. (ProFractional Palo Alto, Calif., USA): They have
developed two microfractional handpieces for their Er:YAG laser base
unit. One handpiece uses a 250-m spot to vaporize tissue from 25 to
1,500 m per pass with treatment densities (coverage) from 1.5% to 60%.
The other uses a 430-mm spot with predetermined densities of either
5.5% or 11%. The latter offers the ability to add depth-selectable tissue
coagulation for enhanced collagen remodeling by delivering a train of
subablative laser pulses that heat the tissue to three selectable depths:
level 1, up to 50 m; level 2, up to 100 m; and level 3, up to 150 m.
3. Almas fractional Er:YAG laser: This is essentially a supercial
epidermal ablative lasers. It uses a microlens arranged in a matrix of
either 9 9 microbeams with energies up to 17 mJ or 7 7 microbeams
with energies up to 28 mJ.
The channels produced by this laser measure 120140 m in depth and
150 m in diameter, limiting treatment to the epidermis and supercial
papillary dermis. The treatment density is increased by performing
multiple passes.
4. Fractional Erbium:YSGG Laser: Cutera (Brisbane, Calif. USA) was

the rst company to develop an Er:YSGG laser for supercial skin
resurfacing. With a water absorption coefcient roughly one-third that
of the Er:YAG laser and ve times that of the CO2 laser, it vaporizes tissue
with a zone of coagulation approximately midway between that of the
CO2 and short-pulsed, or cold, Er:YAG laser. In 2008 they developed
a fractional Er:YSGG laser (Pearl) with a pulse duration of 600 s and a
spot size of 300 m. It produces scans of variable densities and patterns
up to 12 14 mm, ablating up to 100 m in depth with a coagulation
zone of ~40 m.
New Fractional Devices

When the concept of FP was rst introduced, the laser was used as the energy
source to generate fractional damage to the skin. The laser is still the most
common energy source used in FP procedures. Its ability to quickly deliver
energy in the form of focused optical radiation with high precision into small
conned zones makes the laser a modality well suited for FP. Recently, other
energy sources have emerged for generating fractional damage patterns.
For example, radiofrequency (RF) and ultrasound devices are now
commercially available that generate a pattern of small and conned thermal
damage zones in skin tissue. The shape and anatomical location of MTZs
generated using such modalities typically differ from those induced by
focused optical radiation because of a different energy distribution within
the tissue. Further investigations are needed to investigate how the size
and location of thermal lesions generated using RF and ultrasound sources
affect the clinical outcome as compared to laser-generated MTZs. Also more
importantly, it is important to compare these technologies with the existing
devices for similar indications. These are discussed in detail in section 2 of
the book.
Fractional Ablative Radiofrequency

As RF energy quickly diverges with increasing distance from the delivering
electrode, it is possible to generate a spatially conned RF generated thermal
injury only within the tissue directly adjacent to the tip of a needle electrode.
Depending on the location of the tip of such RF electrode, damage can be
generated either at the skin surface, or virtually at any depth by inserting
needle electrodes into the skin. The use of stamping techniques with arrays
or linear arrangements of multiple needle electrodes allows for coverage of a
treatment area within a reasonable time.
Results
A study by Trelles MA (2014) used a newly developed high-power device
for patient of acne scars (iPixelTM RF, Alma Lasers, Caesarea, Israel). The
improvement in scarring was about 57% on the face and 49% on the back and
shoulders. More importantly a comparison study with afractionalerbiumdoped glass 1,550-nm device found no significant difference (Rongsaard N
2014).
Thus, it is our opinion that it is unlikely that this device will prove superior
to the existing laser devices for acne scars.
IntenseFocusedUltrasound(Ulthera Inc.)
Focused ultrasound non-invasive generation of conned lesions, in skin layers,
such as, the deep reticular dermis or even the supercial musculoaponeurotic
system (SMAS) without causing any surface damage. The MTZ cross section
of RF or ultrasound generated MTZs is typically larger than that of laser
generated MTZs because laser radiation can be more focused. However, the
ability to focus optical radiation decreases with increasing skin depth due to
scattering and absorption of optical radiation (Laubach HJ. 2008). The actual
utility in acne scars is not established as yet, but it must be noted being a new
device, complications may arise as noted recently (Jeong KH. 2014).
Fractional Thulium Laser

The superficial depth of this device makes it useful for removal of supercial
pigment, including for non-facial areas. This system can produce a larger MTZ
diameter up to approximately 600 m. Its wavelength is more supercially
absorbed (OPD 100 m) as compared to the 1,540 nm or 1,550 nm lasers
(OPD 1,000 m) but less absorbed than the CO2 lasers (OPD 10 mm).
Thus, it is designed to generate thermal injury in relatively supercially tissue
without signicant disruption of the epidermal barrier.
Though, a few studies have been published (Ho SG, Lee HM), it is the
authors view that unless a objective scoring by a mexameter combined with
clinical improvement is seen, mere subjective improvement is not enough to
justify its use in melasma, especially in pigmented skin.
HOW TO INTERPRET DEVICE DATA ?

During the past 2 years multiple different fractional CO2 lasers have been
developed, some of them having no FDA/CE approval and little or none
histological data.Though the same basic principles apply to all these systems,
the power and delivery systems of the individual units vary considerably.
Lower power lasers have pulse width longer than the thermal relaxation time
of skin and produce larger zones of coagulation beyond the ablated wound,
which affects the safe, allowable treatment depth and surface area coverage.
Thus, the practitioners should, therefore, be familiar with the histologic and
clinical correlation of varying parameters with the fractional ablative device,
they are using.
a. Ask always about histological data and the pulse width, any pulse width
that is markedly high, should be used with caution as it will cause more
damage than required.
b. There is no study to prove that smaller the pulse better the results. Thus,
it is the authors opinion based on the present data that a superpulse or
ultrapulse system may not have a markedly different clinical result from
other modes of CO2 lasers, as far as fractional lasers are concerned.
c. There is also little data to prove that NAFR is superior or inferior to AFR.
d. It remains unclear what constitutes the ideal combination of ablation and
coagulation or treatment depth and density. It is also unclear whether
varying the pattern of ablative or coagulative injury or delivering them
sequentially or simultaneously will be most benecial.
In effect if the laser device has a histological dose depth analysis study and
a FDA/CE approval, changing the dose parameters can lead to a adequate
clinical result. Thus instead of running after the latest fractional laser optimal
use of the existing device makes more sense. The data provided in Table 4.3
can help compare the various devices.
VARIABLES THAT AFFECT FRACTIONAL LASER TREATMENT

Size of Wound
Microwound
In the most common approach, 75-150 m-wide microwounds are created
in the skin with densities ranging from 100 to 1500 microwounds/cm. In
a typical scenario, approximately 3-10% of the surface area of the skin is
involved per pass, with typical pass numbers ranging from three to eight, so
that total involved surface areas tend to range from 15% to 30% per session.
This category has both ablative and nonablative fractional devices.
Ablative devices with microwound approaches are the Profractional laser
(Sciton, Palo Alto, CA), equipped with a scanned microbeam, as well as the
newly introduced Palomar 2940 nm handpiece and finally the Pixel Erbium
YAG laser from Alma (Alma lasers, Buffalo Grove, IL). Reliant technologies
(Mountain View, CA) has a newer fractional CO2 laser system (Re: Pair) that
creates 125 m diameter ablative wounds as deep as 1 mm.
Macrowound
Fractional technologies create wounds greater than 300 m in diameter. These
include the KTP laser with a scanner (with approximately 700 m wounds) as
well as the active FX CO2 system (Lumenis, Santa Clara, CA), which creates
an array of approximately 1 mm wide wounds and covers approximately
60% of the surface area per session. Wound depths range from 80 to 150 m
depending on pulse energy. Fluences with these approaches range from 5 to
15 J/cm2.
Wavelength
Based on the water absorption coefficients of their respective wavelengths,
the Er:YAG produces the least amount of coagulation or residual thermal
damage (~10 m), the CO2 laser produces the greatest amount of coagulation
(~100 m), and the Er:YSSG laser lies somewhere in between (~40 m).
As the AFR are ablative the depth of the laser created cavity is primarily
related to the total energy delivered for a given spot size, and relatively
independent of the applied wavelength. It should be noted, that the Er:YAG
typically produces less thermal damage in the residual tissue as compared to
the CO2 laser due to the stronger absorption by water.
On the contrary NAFR do not physically remove tissue, the maximum
depth of MTZs is thus dependent on the optical penetration depth of any
particular laser wavelength. Thus, the approximate optical penetration
depth (OPD) of Nd:YAG (1,440 nm, 300 m) is less than Er:Glass (1,540 and
1,550nm, 1,000 m), but more than Thulium ber laser (1,927 nm, 100 m).
These differences in optical penetration lengths indicate why the Thulium
laser, with a relatively shallow penetration depth, is often used to treat
supercial lesions within the epidermis and papillary dermis, and why the
Er:Glass laser with a relatively larger optical penetration depth can generate
MTZs extending down into the mid to deep reticular dermis.
But it must be understood that there are many other factors that can
influence laser tissue interactions and there are numerous ways to change
the depth of a fractional laser apart from the wavelength.
Pulse Number/Frequency
Several studies have shown that the depth can be manipulated depending
on the number of pulses wherein multiple pulses are superior to single
pulse. The delay between the pulses is crucial. To maintain a steady state
temperature the delay should be 35 times the TRT (thermal relaxation time)
of the target tissue. Thus, the optimal delay ranges from 300 (3 Hz) to 500
millisecond (2Hz) intervals that corresponds to 35 times the TRT. As can be
seen in the Table 4.3, the pulse duration of most fractional devices does not
exceed 3-4 ms.
Practical use of knowing the number of pulses is that there is a nonlinear
increase in depth depending on the pulses used (Fig. 4.8) and thus again a
gross histological data of the laser should be sought from the manufacturer.
Pulse Duration
This is another tool employed to cause either ablation or coagulation
especially in Er:YAG systems. The purely ablative wounds created by the shortpulsed fractional Er:YAG lasers produce increased bleeding intraoperatively,
but may have an advantage in reducing the risk of postinflammatory
hyperpigmentation in patients with darker skin types. By lengthening the
Fig. 4.8: The effect of number of pulses on the depth of the MTZ zone (Asclepion
Laser Technologies, GmbH)
pulse duration, the wounds produced by the Er:YAG laser can be made to
approximate those of the CO2 laser.
The longer pulse duration results in a larger zone of coagulation (Dierickx,
et al.). In addition to providing hemostasis, it seems that the large volume
of collateral tissue coagulation is beneficial for inducing increased skin
tightening. The DEKA system exemplifies this principle as the pulse duration
varies from 200 to 2,000 s. The longer pulse durations used with this system
produce larger zones of coagulation around the ablated channels of tissue.
Palomars fractional Er:YAG when used with a pulsewidth of 0.25ms, leads
to an ablation up to 1,000 m while a coagulation up to ~70 mm is produced
when the 5 ms pulse durations is used. Scitons Profractional laser offers the
ability to add depth-selectable tissue coagulation for enhanced collagen
remodeling by delivering a train of subablative laser pulses that heat the
tissue to three selectable depths. A similar effect of pulse duration and
thermal effects has been seen with CO2 lasers (Walsh et al.).
A prototype of the fractional Er:YAG (Dermablate MCL 31) has a variable
pulse duration from 100 to 1,000 s, which creates various patterns of tissue
damage, with varying coverage rates (Fig. 4.9).
A basic principle that must be remembered is that as long as the pulse
durations are within the thermal relaxation time of individual MTZs, minor
variation of pulse duration should have limited effects on lesion shape.
However, variation of pulse duration over an extended range of pulse proles
will affect the MTZ shape, e.g. ablation depth and/or extent of residual
thermal damage.
Fig. 4.9: The effect of pulse duration on the coverage rate and tissue effect . Note that
higher the pulse duration, more the heat cogulation and larger the coverage rate.
(Dermablate MCL 31:Fr Er:YAG) (Asclepion Laser Technologies, GmbH)
Energy (Fournier et al. and Kono et al.)

The energy is conventionally described in mJ/beam but this is usually an
incorrect way of representing the energy that impinges on the skin. As the
total energy per beam depends on the density, the total energy is: Energy (J)=
Energy/microbeam (mJ) total density (1001,000/cm2 ). To achieve a high
dose we can either increase the energy/microbeam or the density. A simple
way to achieve these high doses is to give multiple passes, which has been
shown to have more side effects and is histologically non-uniform. Another
way is to increase the dose per microbeam.
Hantash et al. had demonstrated that increasing the pulse energy
increased the depth of ablation. Similarly Bedi et al. (2007), examined the
effect of NAFR and found that an increase in pulse energy leads to increases
in the depth and width of MTZs without compromising the viability of
interlesional tissue in vivo and in explant models, provided that the density
of the MTZ is low enough.
Density (Fournier et al. Kono et al.)

The density of the lasers range from 1001000 spots/probe. By manipulating
the density of the microcolumns, a more aggressive treatment may be
achieved in a single treatment. However, when retreating or passing over a
treated area multiple times, a nonuniform damage is achieved.
There are two general techniques currently available for generating the
desired density of MTZs (number per unit area) within the treatment area:
the stamping technique and the rolling technique (Fig. 4.10).
The stamping technique is performed by forming a preset pattern of
multiple MTZs on a skin region within a well-defined exposure area of the
Fig. 4.10: Stamping technique. The second pass and third pass are given at 45
degrees to the first pass
fixed handpiece and then moving the handpiece to another skin region and
repeating until the entire treatment area is covered. The operator has to
change the direction of the passes manually (Fig. 4.10). The density of MTZs
at the end of a treatment session depends on the preset density within the
exposure area of the handpiece and the number of passes performed over
each skin region.
The problem with this mode is that gaps or Moire artifacts are often
seen when the stamping mode is applied, thus most machines now have
a scanning device that produces a randomized treatment pattern with a
blended appearance after treatment.
The rolling technique is performed by continuously rolling the handpiece
across the entire treatment area. It is also referred as brushing technique,
because the movements of the operator are similar to using a paint brush. As
the velocity of the handpiece relative to the skin varies during treatment, the
delivery rate is adjusted automatically in order to maintain a defined, preset
MTZ density per pass. The total density of MTZs at the end of a treatment
session can be estimated as the density of MTZs per pass multiplied by the
number of passes performed.
There appears to be no single best technique for delivering the desired
density of MTZs. The rolling technique can facilitate treatment of larger areas,
while the stamping technique can facilitate the precise treatment of smaller
areas, in particular areas having an irregular surface profile.
Single/Multiple pass (Manstein et al. 2009)

During each nonablative fractional treatment session, a variable percentage
of the skin surface is thermally damaged as a result of the placement of many
individual MTZs. The so called fill factor, defined as the ratio of thermally
damaged surface area to that of the total area, can theoretically vary from 0%
to 100%. It is primarily determined by energy per MTZ, density of MTZs per
pass, and the number of passes. The application of multiple passes results
in clustering of the lesions (microscopic treatment cluster [MTC]). The size
of MTCs increases linearly as a function of the number of passes. Conuent
thermal damage may result in prolonged recovery time and a higher
frequency of side effects.
The fill factor varies from 1020% for each treatment session. With
fractional thermal injury confined to multiple small thermal lesions,
migration from surrounding epidermal keratinocytes allows for rapid healing
and therefore, lowers the risk of complications. Therefore, it is important for
the clinician to understand how the above mentioned exposure parameters
affect the resulting thermal damage a knowledge of the pattern generated.
This can help as multiple passes can lead to a higher degree of PIH
(Fig.4.11).
Surface Cooling and Temperature (LaubachHetal.

and Fournier et al., 2005)
It has been suggested that microcolumn separation may also be dependent
on fluence and skin temperature. It is important to note the role of contact
Fig. 4.11: A figurative depiction of the effect of number of passes and cover rate on the
fractional laser effect on the skin (fill factor) (Asclepion Laser Technologies, GmbH)
cooling with fractional nonablative laser treatments and the relationship

to microthermal damage, depth and width of the columns. Cooling of the
epidermis can be achieved by two techniquesdynamic and parallel cooling.
Parallel cooling is contact cooling provided during a long laser pulse or a
sequence of pulses. It can protect the epidermis by a factor of 10. Dynamic
cooling is a concomitant cooling process and is seen in the newer fractional
lasers. Advanced lasers have a precooling and postcooling concomitant with
the contact cooling.
In a study on the importance of cooling, a 1,550 nm fiber laser (Fraxel
SR Laser) was used in a dose of 10 mJ on cadaver skin. It was found that
the average MTZ diameter exhibits a positive, linear relationship with skin
temperature. As the skin temperature increases from 0 to 45 the MTZ
diameter increases from 93 to 147 micron (58%), and the MTZ area from
6,870 to 17,050 micron (148%). Thus, skin cooling is a double-edged tool;
while the use of simultaneous skin cooling increases patient comfort, it also
decreases MTZ size and it may interfere with treatment efficacy. The control
of skin temperature is necessary to provide a consistent outcome and to be
able to compare treatments.
Interestingly, reduction of MTZ dimension due to decrease of tissue
temperature have been shown to be more marked for NAFR as compared to
AFR. An interesting aspect of this is that during AFR procedures, a substantial
part of the laser energy is removed from the tissue with the hot laser plume.
This is not seen in NAFR and thus for the same applied energy per MTZ
energy and MTZ density, the overall (bulk) heating of tissue is greater for
NAFR. Thus, NAFR may be better for remodeling collagen.
Correlation of Energy and Depth (Farkas 2009, Sardana K)

It is a logical conclusion that increased energy would lead to increased depth
of penetration. This correlation is essential to quantify the dose required for
dermatological indications like acne scars where depth is an important issue.
Higher energies create deeper columns and disruption of the epidermis
and DEJ. Dermal appendages and microvasculature remain anatomically
intact, but evidence of thermal damage and streaming of nuclei without total
destruction have been demonstrated.
Though not all laser manufacturers have data on the depth a few have well
conducted studies and an approximate depth/mJ dose is given in Box4.1 for
quick reference (Sardana K). Thus if a depth of 1,000 m is needed using the
Lux Palomar a dose of 70 mJ should suffice. Conversely a low dose may have
little effect.
As discussed in Box 4.1 many factors can affect thermal damage patterns
generated in the skin and subsequent wound healing responses. Such factors
include laser exposure parameters (e.g. energy per MTZ and focal spot size),
the number of passes and time interval between them, mechanical tissue

Box 4.1 A rough assessment of dose depth of common lasers systems
Laser
Company
Depth/mJ
NAFR
Lux Palomar
Fraxel
12.9
28.5
AFR(Er:YAG)
Lux 2940 nm
Profractional 2940 nm
54.38
3
AFR(CO2)
ActiveFX
DeepFX
Fraxel repair
MedArt
6.28
53.66
20
12
Abbreviations: NAFR, Non ablative fractional resurfacing; AFR, Ablative fractional resurfacing
manipulation, use of skin cooling procedures, and others. The treatment

interval between individual passes within a single treatment session and
the number of sessions can also be varied. This virtually unlimited number
of possible treatment combinations provides the possibility of tailoring
patient treatment protocols to specic needs, which is still not completely
researched.
INDICATIONS
Though an elaborate list of conditions have been reported to respond to the
technology (Table 4.4) including poikilodermatous disorders, not all patients
or dermatoses achieve optimal results (Tierney et al.). Indications that have
shown some promise for treatment using NAFR in small case studies are
minocycline-induced hyperpigmentation, granuloma anulare, striae, Nevus
of Ota and alopecia areata. A detailed discussion of the common indications
will follow in the next chapter.
Treatment
Principles
a. For higher energies, the spatial density of MTZs formed in the treatment
region should be decreased.
b. When multiple passes are performed on a treatment region, the time
interval between passes should be long enough to allow the tissue to
cool down between consecutive passes.
c. External cooling, e.g. forced air cooling, can be used to remove some
heat from the tissue region being treated.
d. Individual MTZs should induce wound healing but not fibrosis.
e. Confluent damage and bulk heating should be avoided.
f. The cumulative MTZ density should be sufficiently high to result in
clinical improvement after the completion of a treatment course.

Table 4.4 Indications for therapy with fractional lasers
Fractional lasers
Indications
Ablative fractional lasers
Acne scars (Rolling/boxcar)

Other scars
(Traumatic, surgical, atrophy scars, burn scars)
Striae distensiae
Moderate and deep wrinkles
Skin laxity
Solar elastosis
Dyschromia
Melasma (Epidermal)
Poikiloderma
Photo-induced wrinkles
Non-ablative fractional lasers
Acne scars (Rolling/boxcar)

Rejuvenation
Mild to moderate photodamaged skin
Fine wrinkles
Pigmentary alterations
(Poikiloderma, dyschromia,
hyperpigmentation, melasma,
lentigenes, tattoos)
Vascular abnormalities
Skin texture
Preoperative Evaluation/Management
The ideal candidate is a fair skinned patient (skin types I-III). But the
remarkable safety profile makes fractional laser resurfacing ideal even for
darker skin types. It can also be used for extrafacial sites like the neck, trunk,
and extremities.
A complete medical history should be taken for herpes labialis, keloid or
hypertrophic scar formation, post-inflammatory hyperpigmentation (PIH),
isotretinoin use, topical retinoid use and lidocaine allergy.
Contraindications to NAFR include oral isotretinoin within 6 months to
1year of surgery, active skin infection and unrealistic patient expectations.
Nonablative fractional resurfacing may occasionally trigger reactivation
of herpes simplex infection. Prophylactic antiviral medications is initiated
only in patients with a history of recurrent herpes infection and are given the
day before the procedure and continued for 3 to 5 days. Patients with a history
of dry skin are advised to discontinue tretinoin cream 1 week before NAFR to
prevent skin irritation.
A prophylactic antibiotic course (levofloxacin 500 mg twice a day to be
started 2 days before to 3 days after surgery) can be given. An oral analgesic
(brufen/ketoroalc) half hour before the procedure is better than giving topical
anesthesia.
In patients with darker skin types in particular, use of bleaching creams

(hydroquinone 4%), coupled with a sunscreen, can decrease the risk of PIH,
though there is little evidence-based literature for this practice.
External eye shields are advisable. A smoke evacuator should be used
during laser irradiation because all ablative lasers produce a plume.
Patients should have realistic expectations from the procedure. They
should be aware that the treatment will improve fine to moderate wrinkles,
pigmentation, and superficial scars, but will not completely eliminate deep
wrinkles or ice pick scars. As botulinum toxin (BTX) is not deactivated by
the laser energy it may be injected prior to laser therapy (Semchyshyn et al.).
Ideally, BTX is administered 1014 days before laser intervention to enable
its full effectiveness. A flattened skin surface may help to treat the dermal
compartment more uniformly and to provide access to deeper photodamage.
Finally, the muscle relaxation properties of the toxin may contribute to
uniform dermal remodeling.
Intraoperative Procedure
Topical anesthesia is not always essential but the use can decrease the
discomfort and also helps to track the pattern of passes. It is believed that
EMLA can increase the moisture of the skin and as water is the primary
chromophore of AFR this can influence the results. Nevertheless, most
clinicains will use topical anesthesia where tetracaine based topical creams
are preferred as they have a faster onset of action. Conventionally, though
most clinicians use topical anesthesia but contact cooling, ice packs and even
pain killers can suffice in most cases. In case topical anesthesia is used it is
better to not take an immediate photograph as the blanching and erythema
can alter the surface morphology. Immediately prior to the laser intervention,
all makeup, creams, and other substances need to be removed from the skin
surface because they may absorb, scatter, or reflect the photons, causing
overheating at the epidermis.
Method of Use
There are numerous methods to use the probe. All have a singular aim of
providing 34 passes.
Scanning Mode
In the new systems the concept of pitch is used (Figs 4.12A and 4.12B). This
can range from 200 m to 2,000 m. As a thumb rule, the smaller the pitch,
the higher the cover rate (Fig. 4.12B).
Conventionally, three types of pitch can be set (Fig. 4.12C).
Fig. 4.12A: Correlation of pitch on cover rate

Pitch = 200 m to 2,000 m; the smaller the pitch, the higher the cover rate; density = a/b
Fig. 4.12B: Cover rate is defined as the percentage of treated skin and is
dependent on the pitch
Normal mode: When this scan mode is selected, the area is treated by
scanning the lines from left to right and from right to left, starting at the first
line from the top to the last line at the bottom.
Interlaced: When this scan mode is selected, the area is treated by first
scanning the odd lines and then the even lines from the top to the bottom.
Then the even lines are scanned from the bottom to the top. This mode is
advisable for reducing the thermal effects during treatment.
Autofill scan mode: When this scan mode is selected, the area is treated and
scanning the dots with random order: this minimizes the tissue overheating
and then the thermal damage.
Fig. 4.12C: The patterns of scanning mode in fractional lasers
Stamping Mode
In this one pass is given, then the probe is turned by 45o to the right and a
second pass is given and then the probe is brought back to the initial position.
Then a similar pass is given to the left. Unless indicated, multiple passes over
the same area should be avoided (Fig. 4.13).
A second method described is as follows:
The hand piece is placed in full contact with the skin, and the foot pedal is
depressed. A double pass, 50% overlap technique is used, (a) Deliver 1 pass,
(b) come to a complete stop, (c) then pull back to deliver the second pass with
100% overlap and (d) move the hand piece laterally by 50% and repeat steps
(a) to (c).
Dose
The dose of each laser varies according to the indication. Almost all US FDA/
CE approved lasers have a histological dose depth-analysis to predict the
Fig. 4.13 : A single pass on the center of the cheek and overlaping passes on the
preauricular area using the stamping mode (Fractional Er:YAG)
dose. This is especially useful in dermal pathologies like acne scars. A general
rule is difficult to detail for the different laser systems available but a few
principles are given below:
1. As a general rule, higher densities and lower doses are used for
epidermal pathology while a lower density and higher dose is used for
dermal disorders.
2. When treating moderate to severe photodamage or scars, higher pulse
energies and treatment densities are required.
3. Less aggressive treatment parameters are required for eyelid,
preauricular, jaw-line, and neck skin.
4. If a combination of treatments is planned, a nonablative laser treatment
should precede the fractional ablative treatment, and superficial
macroablation should follow the deep fractional treatment.
Sittings
About 35 sittings are done at a interval of 68 weeks. There is a little
improvement after the 4th session.
Post-operative Instructions
1. In case of AFR it is useful to apply cold compress for minimum
30 minutes or cold air. Do not apply ice. For NAFR cooling is not always
required.
2. We ask the patients to apply Aloe Vera 40% gel and ask the patient to use
a sunblock. Also, till the bronzing peels off, the patient is asked to avoid
Fig. 4.14: Simultaneous presence of bronzing in the preauricular area with erythema
on the other areas of the face. Note the pattern of the fractional laser of the facial
skin, which is transient and inevitable
going out in sunlight without protection. The MTZs, which account for
the bronzing (Fig. 4.14) peel off by day 37.
3. In case of aggressive AFR therapy, anti-inflammatory medication and
antibiotic medication can be considered.
4. Inflammatory acne flares have been reported, especially with more
aggressive settings. For acne prone patients, it is best to initiate an oral
antibiotic prior to treatment and continue for 1014 days post-laser, we
prefer levofloxacin 750 mg OD.
5. Post-operatively, sun avoidance, compliance with medication and
proper recognition and management of complications are key.
Side Effects
Predictable Side Effects
Postoperative discomfort, which is generally mild and transient

Sunburn sensation for approximately 1 hour postoperatively
Sunburn like erythema that may persist for 3 to 7 days
Edema, which is generally minimal and usually resolves in 2 to 3 days
The density pattern of the laser manifests after one day and lasts for a
week
Bronzing, which is usually noted on the third postoperative day and
often lasts for 3 to 4 days
Flaking that is often mild and is noted to start on the third postoperative
day and persists for 3 to 4 days
Occasionally petechiae may be seen.
Other Adverse Side Effects

Laser nicks, which are superficial scratches that can occur secondary to
incomplete contact of the handpiece with the skin or secondary to tilting
or lifting the handpiece while the foot switch is still depressed
Blistering and crusting, although this is not common
Reactivation of herpes infection. Antiviral therapy is recommended for
patients with a history of herpes labialis
Postinflammatory hyperpigmentation, especially in darker skin types. It
usually resolves over the course of several months and can be prevented
or decreased by pretreating the patient with bleaching creams. This can
also be avoided by decreasing the density and dose per sitting
Hypertrophic scarring, although very rare, can occur secondary to bulk
heating. Extra caution should be exerted when treating smaller areas
such as the upper lip with high fluencies to avoid bulk heating.
CONCLUSION
There are numerous issues that can be discussed regarding the technology
some of which are beyond the scope of this book. We will focus on the needless
comparison of AFR and NAFR and detail some of the hitherto unresolved
issues that involve the use of fractional lasers.
AFR vs NAFR
The question of comparing the two differing technologies frequently leads
to a lively discussion without any relevant conclusions. The numerous
parameters that can influence the depth and width of the MTZ coupled
with the variation in collagen remodeling dynamics further complicates the
issues. However, histological analysis indicates that NAFR procedures may
even exhibit a greater total volume of denatured collagen, as compared to
an AFR process performed with similar energy per MTZ (comparison of
data from Hantash et al. and Thongsima et al.). The depth of the various
laser technologies and their tissue effects is rarely the focus of research and
whatever little exists (Thongsima et al. Baily et al. Zelickson et al., Sardana
K et al.) has highlighted the fact that given the optimal dose settings of the
available technology there may be little to choose between NAFR and AFR.
The two clinical studies addressing this issue (Cho et al., 2009, Manuskiatti W
et al.) have found no difference between the two technologies. Considering
that most of the major laser manufacturers dabble in both the technologies,
clinical comparison studies will be hard to come by considering the cost of
possessing both the technologies. This is more so as like companies are not
willing to share these data.
We believe that all the present fractional lasers if used in the optimal
settings can achive similar results and the laser practitioner should learn to
optimize settings instead of changing technologies.
Gray Areas in Fractional Lasers

Even though literature is replete with data on fractional lasers, there are
numerous issues that have yet to be discussed. A few are pointed below, and
instead of buying the best available machine, it may better to understand
the technology to maximize results with whatever device that is available:
1. Tissue effects related to pulse duration and/or temporal pulse prole
have not yet been characterized in detail, but these parameters are likely
to be the focus of future studies for optimizing FP procedures.
2. It is a widely held belief that analogous to traditional ablative procedures,
the amount of residual thermal injury in AFP procedures may also be
affected by the temporal prole of the laser pulse. Typical temporal
proles for energy delivery include continuous wave (CW), superpulsed,
and ultrapulsed mode. Although, such dependency of thermal injury on
pulse prole appears reasonable, there is currently no investigational
data available that specically relates the extent of thermal damage for
AFP procedures to the temporal pulse proles. Thus there is no objective
clinical advantage of an AFR over a NAFR.
3. There appears to be no single best technique for delivering the desired
density of MTZs. The rolling technique can facilitate treatment of larger
areas, while the stamping technique can facilitate the precise treatment
of smaller areas, in particular areas having an irregular surface profile.
4. The balance between wound healing, neocollagenesis, coagulation and
remodeling for optimal skin tightening and rejuvenation with fractional
technology warrants further investigations. In Asian skin though it has
been confirmed that it is better to increase the dose/microbeam than
increase the density to achieve an equivalent energy.
5. The optimal settings for coagulation vs ablation and more importantly
the effect of that on the conditions to be treated have not been studied.
6. The variations in skin type have been not addressed, as most Asian
studies are in skin types (I, II, III) that are not representative of darkly
pigmented skin.
The innumerable variables and the choice and control of all possible
parameters and factors is rarely the focus of studies. The multivariate
complexity of FP procedures explains in part the current lack of clinical studies
comparing the effect of many specic FP parameters on patient outcomes. In
spite of this complexity, it turns out that most FP treatment regimes result in
some kind of clinical improvement for appropriate indications.
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Nouri K (Ed). Lasers in Dermatology and Medicine, Springer-Verlag London
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2. Kauvar ANB, Warycha MA. Wrinkles and Acne Scars:Fractional Ablative Lasers
In Raulin C. and Karsai S. (Eds), Laser and IPL Technology in Dermatology and
Aesthetic Medicine, Springer-Verlag London Limited; 2011.
3. Manstein D, Laubach HJ. Fractional Photothermolysis. Nouri K (Ed). Lasers in
Dermatology and Medicine, Springer-Verlag London Limited; 2011.
4. Wrinkles UP, Acne Scars: Fractional Nonablative Lasers. Lasers C. Raulin S,
Karsai (Eds). Laser and IPL Technology in Dermatology and Aesthetic Medicine
Springer-Verlag Berlin Heidelberg; 2011.
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25. Trelles MA, Martnez-Carpio PA. Attenuation of acne scars using high
power fractional ablative unipolar radiofrequency and ultrasound for
transepidermaldelivery of bioactive compounds through microchannels. Lasers
Surg Med. 2014 Jan 29. doi: 10.1002/lsm.22224.
26. Zelickson BD, Walgrave SE, Al-Arashi MY, Altshuler GB, Yaroslavsky IV, Childs
JJ, et al. Semi-Automated method of analysis of horizontal histological sections
of skin for objective evaluation of fractional devices. Lasers Surg Med. 2009;
41(9):634-42.
LASER TREATMENT OF COMMON CONDITIONS

Though a long list of conditions have been treated by these devices, scars
and probably photodamage are the primary indications. There are case
reports suggesting a multitude of other uses, but it is our opinion that newer
fractional lasers, like thulium, Nd:YAG and Qsw ruby may have to be used
to target most of the other indications, specifically melasma and pigmentary
disorders.
ACNE SCARS
There are numerous ways to classify acne scars and the heterogeneity in
their classification makes clinical trial comparisons difficult. For practical
purposes a simple classification is based on the morphology, i.e. rolling,
boxcar, icepick and hypertrophic scars is ideal as this enables a simple
interventional protocol as given in Table 4.5.
How do Fractional Lasers Help in Postacne scarring?

As we have seen, fractionated photothermolysis produces small vertical
zones of full-thickness thermal damage by a mid-infrared laser. This is akin
to sinking posts or drilling holes of thermal damage with areas surrounding
these posts left free of damage. This is a method of ablative resurfacing without
the patient having to experience a pronounced healing phase. Conceptually
it may be the laser equivalent of skin needling and would be expected to have
a significant role in the treatment of scars.
But the effect of the fractional lasers varies depending on the type of
atrophic scar treated. This is as in the deep boxcar and icepick scars, a
volumizing effect is needed to fill up the defect, which requires heat induced
collagen remodeling (Fig. 4.15). This is not easy to achieve as the very purpose
of fractional lasers was to minimize damage.
As the depth of scars vary, a combination of conventional laser (Cho et
al.), AFR (Kim et al., 2009), CROSS (Kang et al.) and subcison should be used
in conjunction with NAFR for best results. A recent review (Sardana K et al.)
has defined the depth of penetration of various systems with NAFR laser
(Er:Glass, 679 m) achieving a depth that was less than that of the AFR lasers
(Er:YAG, 825 m, and CO2 895 m; P < 0.05). But this difference may not be
relevant on the facial skin as the total depth is 2,196 m.
Rolling Scars
Rolling scars occur deep in the follicle and are the end products of inflam
mation that causes destruction of the subcuticular fat. Abnormal fibrous
anchoring of the dermis to the subcutis leads to superficial shadowing and
a rolling or undulating appearance to the overlying skin (Figs 4.15 and 4.16).

Table 4.5 A practical intervention based on morphological type of scars
(Goodman GJ, 2007)
Scar
Treatment modality
Ice pick scars
Punch excision, CROSS

Lasers
Ablative and non-ablative fractional lasers are largely ineffective
against ice pick scars
Boxcar scars
(i) Shallow boxcar scars
Dermabrasion, subcision, dermaroller lasers

Fractional lasers are useful
(ii) Deep boxcar scars
With regular base

Punch floatation if diameter < 3.5 mm, elliptical excision and
suturing if diameter > 3.5 mm
With irregular base
Punch excision with primary closure or graft replacement if
diameter < 3.5 mm
Elliptical excision and suturing if diameter > 3.5 mm
Fractional lasers
The volumizing effect is not sufficient for most deep scars
Rolling scars
Subcision, dermal fillers

Fractional lasers
They consistently respond and are an ideal indication for this
technology
Hypertrophic scars
Intralesional steroid, cryosurgery
Fig. 4.15: The effect of fractional lasers on acne scars

(A) Rolling scars respond due to snapping of dermal bands. Post-treatment (------)
(B) Deep icepick scars and boxcar scars need collagen remodeling to fill the tissue
defect which may not completely eliminate the scars. Post-treatment (------)
They are amenable to fractional lasers (Figs 4.16 and 4.17) as the MTZ
snap the tethered fibrotic bands.
Ice Pick Scars

Ice pick scars are narrow (<2 mm), deep, sharply marginated epithelial tracts
that extend vertically to the deep dermis or subcutaneous tissue. The surface
opening is usually, but not always, wider than the deeper infundibulum as
Fig. 4.16: A case with predominantly rolling scars treated with the Er:Glass (Lux
Palomar)
(Sardana K, et al. Which type of atrophic acne scar (ice pick, boxcar, or rolling)
responds to nonablative fractional laser therapy? Dermatol Surg. 2014;40(3):288-300)
Fig. 4.17: Post-therapy improvement using the Lux Palomar after 6 sittings (70 mJ/4
passes/10 mm)
(Sardana K, et al. Which type of atrophic acne scar (ice pick, boxcar, or rolling)
responds to nonablative fractional laser therapy? Dermatol Surg. 2014;40(3):288-300)
the scar tapers from the surface to its deepest apex (Fig. 4.15). They do not
respond effectively to most fractional lasers eventhough the laser may help to
fill some of the defect.
Boxcar Scars
Boxcar scars may be shallow (0.10.5 mm) or deep (>0.5 mm) and are most
often 1.54.0 mm in diameter (Fig. 4.15). Shallow boxcar scars are within the
dermal reach of skin resurfacing treatments (such as laser skin resurfacing),
but deeper boxcar scars are resistant to improvement in the absence of fullthickness treatment of the scar. For boxcar scars, fractional technologies
should be considered , depending on the patients expectations and tolerance
for downtime. This can be appreciated in Figures 4.18 and 4.19.
Fig. 4.18: A case with large Boxcar atrophic acne scars treated with the
Lux Er:Glass (70 mJ)
Fig. 4.19: After 6 sessions an appreciable improvement is seen, but the volume
defect in the scars may require non-laser modalities
Literature Overview and Critique

The numerous studies published on acne scars , entice the practitioner into
believing in the superlative efficacy of lasers. No doubt there are certain
advantages, like the fast procedure and less downtime, but the results have to
be interpreted cautiously, as most studies either do not subclassify the types
of scar nor do they use a objective tool to quantify results (Tables 4.6 and 4.7).
Thus, the plethora of data has to be understood in respects to three
important aspects:
1. Very few studies have used a objective scoring pattern.Thus a quartile
improvement is highly subjective and can mean little as assessment of
depth improvement is difficult as it is requires a 3-D aspect.
2. Objective analysis has shown a realistic improvement of 43% to 79.9%
with a mean level of improvement of 66.8% (Anne M Chapas). In fact
subjective improvement is always more than objective improvement.
Fig. 4.20: A diagrammatic depiction of the volumizing effect on deep atrophic scars.
The tethered rolling scars respond well to fractional lasers
Scars treated
Moderate to severe
acne scars
Moderate to severe
acne scars
Nonacne
scars
Acne scars
Anne M Chapas,
(2008)
13 patients
Susan E Walgrave
(2009)
30 patients
Elliot T Weiss
(2010)
15 patients
Sung Bin Cho

(2009)
20 patients
Deep Fx
Active Fx
Fraxelre:pair
Fraxelre:pair
Fraxelre:pair
Laser
10 to 20 mJ,
density 2, and 300 Hz using
the Deep FX mode
2 sittings
20 to 100 mJ/pulse, 100 to 300

MTZ/cm2 per pass, density
of 100 to 900 MTZ/cm2 13
passes, 3 sittings
20 to 100 mJ/pulse,
6001,600 MTZ/cm2,
4 sittings
Energies of 20100 mJ /pulse,

spot size = 120 mm, 10400
MTZ/cm2
total densities of 2001,200
MTZ/cm 2
23 sittings
Dose/sessions
Table 4.6 Summary of studies of AFR fractional laser in acne scars
Authors/Number of
patients studied
Yes
No
Quartile scale
Quartile scale
Assessment
subjective
No
Yes,
Primos
Photography
(but subjective
observer
evaluation)
Primos imaging
Assessment
objective*
Contd...
1 = 76% to 100%
9 = 51% to 75%
7 = 26% to 50%
3 = minimal to no
improvements
Volume improvement
= 26.8% to 57.5%
Mean improvement in
scar volume = 38.0%.
Maximum depths of
reduction 26.3% to
40.9%, with
a mean reduction of
35.6% (at 6 months)
1-25% at 3 months
23/25 improved
The result ranged

from 43% to 79.9%
with a mean level of
improvement of 66.8%
Results/
improvement
Atrophic
acne scars
Acne scars
Moderate to severe
acne scars
Manuskiatti W
(2010)
13 patients
Chan NP, (2010)

9 patients
Wang YS
(2010)
5 patients
Fraxel Re:pair
Fraxel Re:pair
Laser
Quartile scoring
No
30-70mJ
Fraxel repair
30-45 % coverage
1 treatment
Energy 28 J/cm(2); pulse
width 2.5 ms; spot size,
300 m; penetration depth
up to 500 m; degree of skin
coverage, 20%; single pass
2 treatment
Subjective
(clinical
evaluation by
two blinded
dermatologists)
Assessment
subjective
3 sessions
Dose
Photographic
evaluation
Photographic
evaluation
Objective
(ultraviolet
A-light video
camera)
Assessment
objective *
At 2 months posttreatment, all five

subjects showed
some clinical
improvement (four:
mild improvement;
one: moderate
improvement)
Only mild to moderate

improvement after a
single treatment
86% had a subjective
improvement
85% of the subjects

had 25% - 50%
improvement of scars.
While 62% of
subjects had a 50%
improvement in their
scars (6 months )
Results
improvement
*Though photography is touted as an objective measure its evaluation by visual comparison is never accurate as depth analysis requires a 3D perspective. Only
Primos is a truly objective tool
Scars treated
Authors/Number of
patients studied
Contd...
No.
17
10
53
Geronemus 2006 *
Hasegawa 2006
III/IV
Alster 2007
Glaich
2007
Atrophic
scars
Mild to
moderate
atrophic scar
Not stated
Ice pick
Boxcar
Rolling
Scars treated
FraxelSR
1500 nm
FraxelSR
1500 nm
(Ist generation)
FraxelSR 1500 nm
Fraxel
Type of Laser
2-3
3-5
Sittings
Table 4.7 Summary of studies of fractional Er:Glass laser in acne scars
Authors
Contd...
Results
Physician clinical assessments: Moderate to marked improvement in
atrophic acne scarring in all patients
Assessment
Subjective
Results
51-75%
Assessment
(Subjective/Photography with quartile scoring)
Results
4 pts-excellent,
3 pt good
3 pts fair
Assessment
Subjective
Results
22% to 66%
Ice pick25% to 50%
boxcar, 22% to 62%
Rolling scars 29% to 67%
Assessment
Digital photography, high-resolution typographic imaging, and
patient-completed questionnaires
Results
(Improvement/Assessment
No.
27
500
29
12
Authors
Lee HS
2008
IV/V
Weiss
2008
Chrastil,
2008
ChoSB 2009 *
IV
Contd...
Mild/
moderate
atrophic scars
and pores
Mild to severe
Mild to
moderate
scars
Rolling
Boxcar
Ice pick scars
Scars treated
Mosaic
LC 1550 nm
Second-generation
1,550-nm
laser
1,540-nm
Lux Palomar
1550-nm
Fraxel
Type of laser
26
NA
35
Sittings
Results
3 pt-76-100%
5 Pt-51-75%
2 pt-26-50%
2 pt-0%
Mean improvement =26-50%
Assessment
(Subjective/Photography with quartile staging)
Results
50% to 75% improvement in facial and back acne scarring
5 > 75%
5=25% to 50%
1 <25% response
Assessment
Photographic evaluation
Contd...
Results
Physician evaluation: 5075% median improvement
Patient evaluation: 85% of patients rated their skin as improved
Assessment
Subjective
Results
All types of scars improved
Patients assessment= Excellent improvement in 8 (30%), significant
improvement in 16 patients (59%), and moderate improvement in
three patients (11%)
Mean = 51-75%
Assessment
(Subjective/Photography-Quartile)
Results
(Improvement/ Assessment
No.
16
45
20
10
Authors
Yoo KH
2009*
Hu S
2009
TypeIII/IV
Cho SB 2009 ||
II/IV
Kim HJ ,2009
IV/V
Kang HW
2009 ||
IV/V
Contd...
Atrophic scars
Rolling and Ice

pick
Atrophic
Scars
Mild-tomoderate
atrophic scars
Acne scars
Scars treated
Mosaic LC1550nm
+
TCA
+
Subcison
Mosaic LC, 1550 nm

VS
CROSS
Fraxel SR1500
Combined with
AR(ultraPulse CO2)
Fraxel 750
Fraxel 1500
Lux 1540 m
Type of laser
Sittings
Contd...
Results
All subjects improved by 55%
Assessment
(Objective scar evaluation but subjective improvement scores)
Results
Rolling scars and ice pick both improved
By 2575%
For Rolling scars Er:Glass is better
Ice Pick CROSS
Assessment
(Subjective/Photography Quartile)
Scars Improved
Results
60% pt-good to excellent
40% pt-none to fair
No signficant d/f b/w two lasers
Assessment
(Subjective)
Mild-to-moderate improvement in acne scars

Increase in collagen and elastin
Assessment
Subjective
Results
10
15
30
SB Cho
2010
Hedelund 2010
(RCT split face
study )
Mahmoud
2010
Type IV-VI
Sardana K 2014
Ice pick
Boxcar
Rolling Scars
Acne scars
Atrophic scars
Mild to
Severe
Scars
Scars treated
StarLux
1540 nm
1,550 nm laser
(Fraxel)
With
Triluminacream
StarLux
1540 nm
Fraxel SR1500
vs
Fractional CO2
Type of Laser
4-6
Sittings
Ice pick scar improved by 25.88%

Boxcar scars improved by 52.9%
Rolling scars improved by 43.14%
Subjective improvement
46.7% of pts = 25-49% improvement
30% >50% improvement
Results
Equal response in both groups, significant improvement seen by
patients but with PIH
Observer = 125%
No difference in doses
Assessment
Photography
Quartile
Results
Moderatemarked improvement in 50% pts. No PIH
The observer score came down from moderately even to mildly even
scar texture
Assessment
Subjective
Results
Both lasers
Were Equally good
All pt improved 2650 %
Assessment
Subjective
Results
*Studies where histology was done, Studies where acne scars were subclassified as, ice pick, boxcar and rolling, Though photography is touted as a objective
measure its evaluation by visual comparison is never accurate as depth analysis requires a 3D perspective. Only Primos is a truly objective tool, Comparative
studies, ||Studies where NAFR was combined with other modalities
No.
Authors
Contd...
3. These results are even less impressive if we look at individual scars. Deep
ice pick scars rarely respond to the fractional laser (Sardana K, 2014).
4. Some authors have combined modalities, thus it is difficult to determine
which modality has helped in scar improvement (Table 4.6).
5. Most importantly a comparison of NAFR and AFR has shown that the
results are not markedly different (Table 4.6).
Devices vary in their penetration capacities, and optimal parameters
still need to be dened (Taub et al.) and thus there is still a need for optimal
device usage to achieve satisfactory results.
Based on the available evidence a approach to treating acne scars is given
below (Fig. 4.20).
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the treatment of atrophic scars. Dermatol Surg. 2007;33(3):295-9.
2. Chan NP, Ho SG, Yeung CK, Shek SY, Chan HH. Fractional ablative carbon
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34:1327-32.
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9. Geronemus RG. Fractional photothermolysis: current and future applications.
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10. Glaich AS, Goldberg LH, Friedman RH, Friedman PM. Fractional
photothermolysis for the treatment of postinflammatory erythema resulting
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12. Hasegawa T, Matsukura T, Mizuno Y, Suga Y, Ogawa H, Ikeda S. Clinical trial of a
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2006;33(9):623-7.
13. Hedelund L, Moreau KE, Beyer DM, Nymann P, Haedersdal M. Fractional
nonablative 1,540-nm laser resurfacing of atrophic acne scars. A randomized
controlled trial with blinded response evaluation. Lasers Med Sci. 2010;
25(5):749-54.
14. Kang WH, Kim YJ, Pyo WS, Park SJ, Kim JH. Atrophic acne scar treatment using
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Laser Ther. 2009; 17:1-4.
15. Kim HJ, Kim TG, Kwon YS, Park JM, Lee JH. Comparison of a 1,550 nm
Erbium:Glass fractional laser and a chemical reconstruction of skin scars
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Evaluation of a novel fractional resurfacing device for treatment of acne scarring.
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photothermolysis for the treatment of acne scars in Asian skin: a pilot study.
Photodermatol Photoimmunol Photomed. 2009;25(3):138-42.
PHOTODAMAGE SKIN
The desire to reverse ageing is a universal desire and fractional lasers are
one of the many tools employed for this purpose. The basic premise of the
technology is based on the principles of targeting the dermis (and/or deeper
epidermis) and can be achieved either by:
Targetting chromophores in the dermis
Using devices that are not avidly absorbed by water, like the midinfrared
lasers in the range of 1.31.55m.
Thus, numerous devices can be used from visible (400760 nm), nearinfrared (7601400 nm), or midinfrared (1.43 m) ranges, radiofrequency
(RF) devices (Gold MH, 2014), intense pulsed light (IPL) devices, as well as
light-emitting diode (LED) devices.
Mode of Action
The photothermal heating of the dermis leads to increases collagen
production by fibroblasts and induces dermal matrix remodeling by altering
glycosaminoglycans as well as other components of the dermal matrix.
Richard Glogau, MD, developed a classification scale to chart the
progression of clinical photoaging (Table 4.8) which is a prerequisite for the
use of lasers. It should be remembered that the fractional lasers are primarily
useful in Glogau grade I/II patient and may not affect the pigmented and
vascular changes.
Fractional Lasers Used

Almost all the fractional lasers have been used from non-ablative lasers (1440
nm,1550 nm) to fractional ablative lasers (Er:YAG, CO2, thullium). Recently
fractional Nd:YAG has also been used successfully (Gold MH ).The spate of
data has to be understood objectively (Table 4.9) even though the results may
seem impressive. As the main mode of action is collagen remodeling this
depends on multiple factors , like the grade (Table 4.8) , dose , density, type of
lasers and the aspect ratio of the laser. The last is the depth and width of the
MTZ that has been discussed in the previous chapter.

Table 4.8 Glogau photoaging classification
Grade
Classification
Typical
age
Description
Skin characteristics
Mild
20s or 30s
No wrinkles
Early photoaging: Mild

pigmentary change, no
keratoses, minimal wrinkles,
minimal or no makeup
II
Moderate
30s or 40s
Wrinkles in
motion
Early to moderate photoaging:

Early solar lentigines,
keratoses palpable but not
visible, parallel smile lines
begin to appear, wears some
foundation
III
Advanced
50s
Wrinkles at
rest
Advanced photoaging:
obvious discolorations,
visible telangiectasias, visible
keratoses, wears heavier
foundation always
IV
Severe
60s and
older
Only wrinkles
Severe photoaging: Yellowgray skin color, prior skin

malignancies, wrinkles
throughoutno normal skin,
makeup cakes and cracks
Literature Overview
1. Sadly there is little standardization of trial data (Table 4.9) and except for
a few studies (Ross et al.) histological data is lacking.
2. As the major chromophore for most fractional lasers is water, it is logical
to presume that lesser the absorption coefficient better the results, thus
the 1540, 1550 nm would be better than the ablative fractional lasers.
This is as the primary component of the dermis is water and thus lesser
the absorption more would be the potential for thermal remodeling.
3. As little objective scoring is done in studies, in mild-to-moderate cases
(Table 4.8) the results of all the fractional lasers would largely be similar.
4. Also with little data in pigmented skin, aggressive settings (Pardo et al.)
should be avoided.
5. Most importantly is the persistence of the effect which has been studied
by Lapidoth et al. and found to persist for 69 months. In the rest of the
studies (Table 4.9) long-term follow up has not been done.
Conclusion
Fractional lasers can be considered as one of the tools to treat photodamaged
skin and as an extension rhytides, actinic keratosis (Lapidoth M) and
blepharochalasia (Balzani A, 2014). Patient selection is important to obtain
the best expectationoutcome match. Thus a combination of IPL, KTP lasers.

Table 4.9 Literature overview of fractional lasers in photodamage skin
Author
Laser used
Results
Rahman et al. 2009
Fractional CO2 laser
(50100%) improvement was

observed in 83% of subjects
Pardo et al. 2009
Higher-density coverage
(10.1% ablated tissue)
produces a greater
inammatory
response and improved
results compared to a lower
density of ablation (3.5%)
Weiss et al. 2008
1,550-nm vs fractional CO2
75% improvement compared

to a 25% improvement in
periocular rhytides
Lomeo et al.
Fractional CO2 vs Er:YAG

laser
CO2>Er:YAG
Lapidoth et al. 2008
Fractional Er:YAG laser
Excellent improvement
in 75% (n = 21) and good
improvement in 25% (n = 7)
Ross et al. 2009
Fractional 2,790-nm
Er:YSGG laser
Wrinkle and fine lines

improved
Doherty, 2009
Fractional Er:YAG laser
50% or greater reduction

in perioral and periorbital
wrinkles in 76% of patients
(n = 17) and a more than 25%
reduction in dyschromia in
all patients
Kohl E, 2013
Site periorbital, perioral,

forehead, cheeks
Wrinkles were significantly
reduced in all facial
areas, and the best results
regarding wrinkle size and
depth were found for the
cheeks
PDT, mid-infrared lasers and fractional lasers may be required exemplifying

the complexities inherent in treating photodamaged skin. Thus studies on
lasers should be interpreted both by the amount of improvement and the
type of improvement ! A detailed discussion is given in the chapter of Nonablative laser resurfacing.
Bibliography
1. Balzani A, Chilgar RM, Nicoli M, Sapountzis S, Lazzeri D, Cervelli V, Nicoli F.
Novel approach with fractional ultrapulse CO2 laser for the treatment of upper
eyelid dermatochalasis and periorbital rejuvenation. Lasers Med Sci. 2013;28(6):
1483-7.

2. Doherty S, Seckel B, Ross EV. Advantages of a groove pattern of microfractional
ablation for facial skin resurfacing. Lasers Surg Med. 2009;41:S21 (abstract 84).
3. Gold MH, Adelglass J. Evaluation of safety and efficacy of the TriFractional RF
technology for treatment of facial wrinkles. J Cosmet Laser Ther. 2014;16(1):2-7.
4. Gold MH, Biron JA. Combined superficial and deep fractional skin treatment
for photodamaged skin: a prospective clinical trial. J Cosmet Laser Ther.
2012;14(3):124-32.
5. Kohl E, Meierhfer J, Koller M, Zeman F, Klein A, Hohenleutner U, et al. Fractional
carbon dioxide laser resurfacing of rhytides and photoaging: a prospective study
using profilometric analysis. Br J Dermatol. 2013. doi: 10.1111/bjd.12807.
6. Lapidoth M, YAGima Odo ME, Odo LM. Novel use of erbium:YAG (2,940nm)
laser for fractional ablative photo-thermolysis in the treatment of photodamaged
facial skin: a pilot study. Dermatol Surg. 2008;34:104853.
7. Lapidoth M, Adatto M, Halachmi S. Treatment of actinic keratoses and
photodamage with non-contact fractional 1540-nm laser quasiablation: an ex
vivo and clinical evaluation. Lasers Med Sci. 2013;28(2):537-42.
8. Pardo A, Ciscar E, Alvarez-Suriaca GB. Microablative fractional CO2 resurfacing:
non-invasive objective in vivo assessment using reectance confocal microscopy.
Lasers Surg Med. 2009;41:S21 (abstract 70).
9. Rahman Rahman Z, MacFalls H, Jiang K, Chan KF, Kelly K, Tournas J, et al.
Fractional deep dermal ablation induces tissue tightening. Lasers Surg Med.
2009;41(2):78-86.
10. Ross EV, Biesman B, Green R. Clinical and histological results with a novel 2.79
UM fractionated YSGG laser. Lasers Surg Med. 2009;41:S21 (abstract 100).
11. Weiss R, Weiss M, Beasley K. Prospective split-face trial of a xed spacing array
computed scanned fractional CO2 laser versus hand scanned 1550 nm fractional
for rhytides. Abstract presented at American Society for Laser Medicine and
Surgery Conference, April 2008, Kissi mmee, FL.
RHYTIDES
To achieve satisfactory results with deep or dynamic rhytides, ablative lasers
are usually necessary and ideally a combination of llers and neurotoxins are
used. A few basic principles are given below which are applicable to the use
of fractional lasers in rhytides:
1. Sessions should be given at 4 weeks intervals.
2. About 46 treatments are required for results.
3. Mean improvement seems to be higher in facial than in nonfacial skin.
4. Perioral wrinkles are the most difficult to treat.
NON-ACNE SCARS
Post-traumatic and surgical scars can be treated by multiple methods and
lasers should be used as a adjunct to standard therapies.
At a fundamental level, there is little justification of using fractional
lasers in all cases as the mode of action of these lasers does not lead to
collagen reduction but increase in collagen. In case of hypertrophic scars a

combination with topical steroids may be a useful adjunct (Waibel JS). We feel
that the use of fractional lasers should be largely restricted to post-traumatic
and surgical scars and not keloids. The studies published on this topic throw
up some basic principles that are enshrined in Table 4.10:
Treat scars early ideally within the first 3-4 weeks. A combination therapy
with topical agents may help to augment the results of the laser therapy.
A combination of PDL (Hultman CS) and fractional CO2 may prove to be
a better option as the pulsed-dye laser can target pruritus and erythema,
whereas thefractionalCO2 laser works on the stiffness and abnormal
texture.
Amongst ablative fractional lasers there is an advantage in using
fractional CO2 over Er:YAG
Objective improvement is modest (36%) (Weiss et al).
An overview of scar improvment in a case of post-traumatic scar is depicted
in Figure 4.21A to D.
Conclusion
It has been proposed that the scar treatment paradigms should include
extensive integration of fractional resurfacing and other combination
therapies but the research and studies as yet cannot give any firm guidelines
(Anderson RR).
Some important aspects should guide the reader, before using the frac
tional technology for scars. How many studies use an objective assessment
Table 4.10 Literature overview of fractional lasers in non-acne scars

Author
Fractional lasers
used
Indications
Results
Kim SG, 2012
2,940 nm erbium:
yttrium-aluminumgarnet (Er:YAG)
Traumaticscars
Treat early within

4 weeks of scar
Choi JE, 2014
Er:YAg vs CO2
Hypertrophicscars
Average percentage
changes of VSS was
28.2% for Er:YAG
and 49.8% for CO2
Lee SH, 2013
CO2
Surgicalscars
Treat within the first

3 weeks
Weiss ET, 2010
CO2
Atrophic postoperative
and traumatic scarring
Image analysis
revealed a 38.0%
mean reduction of
volume and 35.6%
mean reduction
of maximum scar
depth
Figs 4.21A to D: (A) Preoperative view of traumatic scar; (B) Immediately after
Er:Glass, note the MENDs seen on the surface; (C) Appearance after one month, note
the edema in the scar; (D) After 6 months marked improvement in the scar
of improvement? How many studies have compared lasers with established

conventional methods of therapy like topical steroids, silicone dressing and
occlusion ? And lastly with very few split lesion studies (Lee SH) it is likely
that a certain degree of scar remodelling may ensue on its own and is credited
to lasers !
Most importantly no single laser can help in scars and in most hypertrophic
scars a combination is required, a vascular-specific pulsed dyelaser(PDL)
to reduce hyperemia, ablative fractional CO2 laser to improve texture and
pliability of the scar, and intense pulsed light (IPL) to correct scar dyschromia
and alleviate chronic folliculitis (Hultman CS, 2012).
Bibliography
1. Anderson RR, Donelan MB, Hivnor C, Greeson E, Ross EV, Shumaker PR, et
al. Laser treatment of traumatic scars with an emphasis on ablative fractional
laser resurfacing: consensus report. JAMA Dermatol. 2014;150(2):187-93. doi:
10.1001/jamadermatol.2013.7761.
2. Choi JE, Oh GN, Kim JY, Seo SH, Ahn HH, Kye YC. Ablative fractional laser
treatment for hypertrophic scars: comparison between Er:YAG and CO2 fractional
lasers. J Dermatol Treat. 2014;25(4):299-303.
3. Hultman CS, Edkins RE, Wu C, Calvert CT, Cairns BA. Prospective, before-after
cohort study to assess the efficacy of laser therapy on hypertrophic burn scars.
Ann Plast Surg. 2013;70(5):521-6.

4. Hultman CS, Edkins RE, Lee CN, Calvert CT, Cairns BA. Shine on: Review of laserand light-based therapies for the treatment of burn scars. Dermatol Res Pract.
2012;2012:243651. Epub 2012 Jun 20. doi: 10.1155/2012/243651.
5. Kim SG, Kim EY, Kim YJ, Lee SI. The Efficacy and Safety of Ablative Fractional
Resurfacing Using a 2,940-Nm Er:YAG Laser for Traumatic Scars in the Early
Posttraumatic Period. Arch Plast Surg. 2012;39(3):232-7.
6. Lee SH, Zheng Z, Roh MR. Early postoperative treatment of surgical scars using
a fractional carbon dioxide laser: a split-scar, evaluator-blinded study. Dermatol
Surg. 2013;39(8):1190-6.
7. NS, Waibel JS. Laser treatment of traumatic scars with an emphasis on ablative
fractional laser resurfacing: Consensus report. JAMA Dermatol. 2013 Dec 11.
8. Waibel JS, Wulkan AJ, Shumaker PR. Treatment of hypertrophic scars using laser
and laser assisted corticosteroid delivery. Lasers Surg Med. 2013;45(3):135-40.
9. Weiss ET, Chapas A, Brightman L, Hunzeker C, Hale EK, Karen JK, et al. Successful
treatment of atrophic postoperative and traumatic scarring with carbon dioxide
ablative fractional resurfacing: quantitative volumetric scar improvement. Arch
Dermatol. 2010;146(2):133-40.
ACTINIC KERATOSES
Apart from the 1550nm the thullium laser has also been used for this
condition. The concept of fractional 1927nm thulium laser is based largely
on the superficial depth of penetration. Importantly though studies have
shown a clinical improvement, histological persistence has also been noted,
and as a result, it has been recommended that NAFR should not be used as a
single treatment modality for actinic keratoses.
Bibliography
1. Pearce DJ, Williford PM. Another approach to actinic keratosis management
using nonablative fractional laser. J Dermatol Treat. 2014;25(4):298. doi:
10.3109/09546634.2012.735641. Epub 2013 Jan 20. PubMed PMID: 23331072.
2. Weiss ET, Brauer JA, Anolik R, Reddy KK, Karen JK, Hale EK, et al. 1927-nm
fractional resurfacing of facial actinic keratoses: a promising new therapeutic
option. J Am Acad Dermatol. 2013;68(1):98-102. doi: 10.1016/j.jaad.2012.05.033.
Epub 2012 Oct 2. PubMed PMID: 23041112.
3. Lapidoth M, Adatto M, Halachmi S. Treatment of actinic keratoses and
photodamage with non-contact fractional 1540-nm laser quasi-ablation: an ex
vivo and clinical evaluation. Lasers Med Sci. 2013;28(2):537-42.
STRIAE
The progressive evolution of striae and its natural course of resolution means
that studies on lasers in the condition should account for this natural course.
Without comparing lasers with other topical agents a firm conlusion of its
efficacy cannot be concluded. But the collagen remodeling action of fractional
laser is an elegant way of buttressing claims of its use. More importantly we

feel that a combination of PDL, excimer and fractional lasers may help more
than a single device alone.
It is our opinion that inspite of the studies, histological improvement
and objective decrease in the lesion have not been as marked to replace
conventional methods of treatment.
A detailed discussion can be found in the chapter on laser treatment of
scars.
Bibliography
1. Alexiades-Armenaka M, Sarnoff D, Gotkin R, Sadick N. Multi-center clinical
study and review of fractional ablative CO2 laser resurfacing for the
treatment of rhytides, photoaging, scars and striae. J Drugs Dermatol.
2011;10(4):352-62. PubMed PMID: 21455544.
2. de Angelis F, Kolesnikova L, Renato F, Liguori G. Fractional nonablative 1540nm laser treatment of striae distensae in Fitzpatrick skin types II to IV:
clinical and histological results. Aesthet Surg J. 2011;31(4):411-9. doi:
10.1177/1090820X11402493. PubMed PMID: 21551432.
3. Gauglitz GG, Reinholz M, Kaudewitz P, Schauber J, Ruzicka T. Treatment of
striae distensae using an ablative Erbium: YAG fractional laser versus a 585nm pulsed-dye laser. J Cosmet Laser Ther. 2013. [Epub ahead of print] PubMed
PMID: 24131065.
4. Yang YJ, Lee GY. Treatment of striae distensae with nonablative fractional
laser versus ablative CO2 Fractional Laser: A randomized controlled trial. Ann
Dermatol. 2011 Nov;23(4):481-9. doi: 10.5021/ad.2011.23.4.481. Epub 2011 Nov
3. PubMed PMID: 22148016; PubMed Central PMCID: PMC3229942.
MELASMA
Though, this topic has been discussed extensively in the previous chapters we
will give a brief overview of the same here with a specific focus on fractional
lasers.
Mechanism of Action
A elegant concept has been propounded for the action of fractional lasers,
whereas the melanin present within the MEND helps to remove the pigment.
In fact as the MEND sheds off it shuttles out the pigment. Also the optical
clearance is believed to take place via melanophage rupture with consecutive
dispersion of melanin within the dermal tissue. In addition, a relative
decrease in melanocytes and a reduction in melanin within keratinocytes has
also been reported.
But there are three important facts that explain the lack of marked clinical
results:
The diameter of the MEND is in m and even if a high density is employed

the melanin that is removed is miniscule
If melasma was a static condition ,which it is not, there may have been a
sustained results ,but being a dynamic disorder the pigment production
compensates for the loss in the MEND. This is more so in pigmented
skin in tropical countries
As discussed previously, only when combined with TC creams and peels
do lasers have some results (Sardana K). In fact a moot point is that
where is the need to combine with other agents if lasers are so effective?
Lasers Used
Apart from fractional ablative and non-ablative lasers, thullium and fractional
Qsw Ruby have also been used for melasma and have been discussed
previously.
Results
Despite individual reports documenting successful treatment of melasma
with NAFR, long-term efficacy of such treatments is still uncertain. The first
pilot study by Rokhsar and Fitzpatrick demonstrated an astounding 75100%
clearance of melasma in 60% of the patients at 3 months. There are numerous
cases of worsening of melasma and Wind et al have shown that probably
a TC cream would be a better option. Our own results have been largely
disappointing (Figs 4.22A and B).
Conclusion
While initial NAFR reports showed promise in the treatment of melasma, it
remains unclear how truly effective these lasers are in treating this chronic,
Figs 4.22A and B: (A) A case of melasma treated with Fractional Er:YAG (Dermabalte);
(B) Minimal response, note the PIH that leads to an aggravation of the condition
stubborn condition and whether lasers alter the natural history of the
condition.
The most complimentary endorsement for fractional lasers comes from a
study by Kroon et al. where they found that nonablative fractional laser therapy
is safe and comparable in efficacy and recurrence rate with triple topical
therapy. It may be a useful alternative treatment option formelasmawhen
topical bleaching is ineffective or not tolerated. Different laser settings and
long-term maintenance treatment should be tested in future studies.
Our own experience with fractional lasers (Er:Glass, CO2 and Er:YAG) has
not been as favorable and we do not find any justification in using this device
for melasma. If this technology has to be used, always use a low energy and
high density.
Bibliography
1. Kroon MW, Wind BS, Beek JF, van der Veen JP, Nieuweboer-Krobotov L, Bos
JD, Wolkerstorfer A. Nonablative 1550-nm fractional laser therapy versus triple
topical therapy for the treatment of melasma: a randomized controlled pilot
study. J Am Acad Dermatol. 2011;64(3):516-23.
2. Rokhsar CK, Fitzpatrick RE. The treatment of melasma with fractional
photothermolysis: a pilot study. Dermatol Surg. 2005;31:1645-50.
Leprol. 2013;79(3):420-2.
4. Taub AF. Fractionated delivery systems for difcult to treat clinical applications:
acne scarring, melasma, atrophic scarring, striae distensae, and deep rhytides. J
Drugs Dermatol. 2007;6:11208.
5. Wind BS, Kroon MW, Meesters AA, Beek JF, van der Veen JP, Nieuweboerrobotov L, at al. Non-ablative 1,550 nm fractional laser therapy versus triple
topical therapy for the treatment of melasma: a randomized controlled split-face
study. Lasers Surg Med. 2010;42(7):607-12.
OTHER PIGMENTARY DISORDERS

There are reports of the use of fractional lasers in post-inflammatory
hyperpigmentation (Lee SJ, 2013) , Beckers Nevus (Ablative CO2; Glaich AS
and Meesters AA), nevus of Ota (Kouba DJ; 1440 nm) , lichen amyloidosis
(Anitha B, 2,940 nm) and even blue minocycline pigmentation , but till more
reports or studies are published they cannot be recommended for use in
these disorders.
Bibliography
1. Anitha B, Mysore V. Lichen amyloidosis: Novel treatment with fractional ablative
2,940 nm Erbium: YAG Laser Treatment. J Cutan Aesthet Surg. 2012;5(2):141-3.

2. Glaich AS, Goldberg LH, Dai T, Kunishige JH, Friedman PM. Fractional
resurfacing: a new therapeutic modality for Beckers nevus. Arch Dermatol.
2007;143(12):1488-90.
3. Kouba DJ, Fincher EF, Moy RL. Nevus of Ota successfully treated by fractional
photothermolysis using a fractionated 1440-nm Nd:YAG laser. Arch Dermatol.
2008;144(2):156-8
4. Lee SJ, Chung WS, Lee JD, Kim HS. A patient with cupping-related postinflammatory hyperpigmentation successfully treated with a 1,927 nm thulium
fiber fractional laser. J Cosmet Laser Ther. 2013 Nov 18.
5. Meesters AA, Wind BS, Kroon MW, Wolkerstorfer A, van der Veen JP, NieuweboerKrobotov L, et al. Ablative fractionallaser therapy as treatment for Becker nevus:
a randomized controlled pilot study. J Am Acad Dermatol. 2011;65(6):1173-9
POIKILODERMA OF CIVATTE
Poikiloderma of Civatte is characterized by hyper- and hypopigmentation,
atrophy, and telangiectasia. As the clinical spectrum suggests, a single laser
will rarely help and ideally a pulsed dye lasers, intense pulse light and KTP
will have to be combined with a fractional non-ablative devices in improving
the overall color and texture in this condition.
Bibliography
1. Behroozan DS, Goldberg LH, Glaich AS, Dai T, Friedman PM. Fractional
photothermolysis for treatment of poikiloderma of civatte. Dermatol Surg.
2006;32(2):298-301
2. Tierney EP, Hanke CW. Treatment of Poikiloderma of Civatte with ablative
fractional laser resurfacing: prospective study and review of the literature. J
Drugs Dermatol. 2009;8(6):527-34. Review. PubMed PMID: 19537378.
MISCELLANEOUS CONDITIONS
NAFR has also been used to treat a host of other conditions including matted
telangiectasias, residual fibrofatty tissue after hemangioma involution,
recalcitrant disseminated superficial actinic porokeratosis, disseminated
granuloma annulare, colloid milium, pearly penile papules, postinflammatory hypopigmentation, alopecia areata and pattern alopecia. This
list will certainly grow but we feel that the most useful indications at present
are acne scars and photodamaged skin.
Bibliography
1. Cho S, Choi MJ, Zheng Z, Goo B, Kim DY, Cho SB. Clinical effects of non-ablative
and ablative fractional lasers on various hair disorders: a case series of 17
patients. J Cosmet Laser Ther. 2013;15(2):74-9

2. Glaich AS, Goldberg LH, Dai T, Friedman PM. Fractional photothermolysis
for the treatment of telangiectatic matting: a case report. J Cosmet Laser Ther.
2007;9:1013.
3. Glaich AS, Goldberg LH, Friedman RH, Friedman PM. Fractional
photothermolysis for the treatment of postinammatory erythema resulting
from acne vulgaris. Dermatol Surg. 2007;33:8426.
4. Lee GY, Lee SJ, Kim WS. The effect of a 1550 nm fractional erbium-glass laser in
female pattern hair loss. J Eur Acad Dermatol Venereol. 2011;25(12):1450-4
5. Yoo KH, Kim MN, Kim BJ, Kim CW. Treatment of alopecia areata with fractional
photothermolysis laser. Int J Dermatol. 2010;49(7):845-7.
FUTURE OF FRACTIONAL LASERS

Usinglaserscan be an effective drug permeation-enhancement approach for
facilitating drug delivery into or across theskin. The controlled disruption and
ablation of the stratum corneum, the predominant barrier for drug delivery,
is achieved by the use of lasers. The possible mechanisms of laser-assisted
drug permeation is the direct ablation of theskinbarrier, optical breakdown
by a photomechanical wave and a photothermal effect.
It has been demonstrated that ablative approaches for enhancing drug
transport provide some advantages, including increased bioavailability, fast
treatment time, quick recovery of SC integrity and the fact thatskinsurface
contact is not needed.
The laser can be used in enhancing the permeation of a wide variety
of permeants, such as small-molecule drugs, macromolecules and
nanoparticles.
This potential use of the laser affords a new treatment for topical/
transdermal application with significant efficacy.

PRINCIPLES
The fundamental principles of FP that guide the selection of treatment
parameters are relatively simple and can be summarized by three basic rules:
1. The dimensions of individual MTZs should not exceed certain
dimensions, such that the induced wound-healing results in tissue
repair rather than inducing brosis.
2. The overall density of MTZs should not be excessively high to maintain
sufcient undamaged tissue between the MTZs and facilitate tissue
repair.
3. The cumulative density of MTZs should be sufciently high to induce
sufcient clinical improvement after a completed course of FP
treatments.
PATIENT SELECTION
The preoperative consultation is crucial to maximize outcomes while
minimizing complications. The clinician should assess the patient
expectations and goals for treatment during this encounter, individuals
with unrealistic expectations should not be treated. Showing patients before
and after photos of a typical result can help to set the patient expectations
regarding the efficacy of treatment. Even so, the patient must also understand
that individual responses can vary.
To achieve satisfactory results about four to six treatments is required
that are spaced at 4-6 weeks interval and thus require 6 months or more to
complete.
Importantly in acne scars deep ice pick and boxcar scars do not respond
as well as rolling and superficial boxcar scars.
Rule out history of keloids, herpes simplex infection, postinflammatory
hyperpigmentation (PIH), current medications including previous
isotretinoin use, lidocaine allergy, pain tolerance, and anxiety level.
CI: Women who are pregnant or lactating, those with active infection,
particularly herpes simplex, and patients with a history of isotretinoin use in
the past 6 months.The last recommendation is debatable as there is evidence
of dermabrasion being undertaken ,while on isotretinoin and even within 3
months of stopping the therapy (Picosse et al. Bagatin et al.).
PREOPERATIVE STEPS
1. Sunscreens: It is advisable to use a broad-spectrum sunscreen (SPF >30)
and to avoid sun exposure before, during and immediately after their
treatments. There is no evidence that treating with topical hydroquinone

for 12 months prior to non-ablative fractional resurfacing decreases the
risk of postinflammatory pigmentation in individuals with darker skin
types (type IVVI). There is no scientific evidence that topical retinoids
need to be discontinued prior to treatment in those with sensitive skin.
We, though prefer using topical retinoids in cases of acne scarring
and a non HQ/Steroid based, depigmenting cream in our patients
(MelaglowTM/Clearz PlusTM).
2. Antiviral prophylaxis should be given only if there is history of herpes
labialis.
3. Anesthesia: There are two options, either using prilocaine based creams
or tetracaine based creams. Anesthetic agents with tetracaine induce
significant erythema leading to patient dissatisfaction. Thus another
option is to use 30% lidocaine.
4. Baseline photograph: In case topical anesthesia is used , it must be
noted that some patients have a blanched appearance thus making
photographic evaluation difficult. Thus a photograph should be taken
before applying the anesthesia.
INTRAOPERATIVE
1. Ensure that the laser handpiece is applied perpendicular to the skin.
2. Scanning Hand Piece: While using the Fraxel systems (Solta Medical,
Hayward, CA) the protocol is eight passes when treating acne scars,
rhytides, and photoaging of the face. A double-pass, 50% overlap
technique is used.
One linear pass is delivered, the handpiece is brought to a complete stop,
lifted, repositioned, and then returned along the same path for a second
pass. The handpiece is then moved laterally by 50% and the technique
is repeated until the treatment area is completed. As a result, each area
is treated with four passes. For the next four passes, the passes are given
perpendicular to the first treatment to ensure complete and even laser
coverage.
3. Stamping hand piece: For stamping handpieces, the fractionated
energy is delivered according to the tip size. The Lux system (Palomar
Medical Technologies Inc., Burlington, MA) and the Acepelion Er:YAG
is example. Here three to four passes are generally delivered with a
50% overlap in both directions. The handpiece should be lifted off the
skin between each pulse, and pulse-stacking is not recommended. The
number of passes and treatment parameters vary with the different
machines and is discussed in the chapter of fractional lasers.
POSTOPERATIVE
Erythema develops immediately afterwards in all treated patients and
typically resolves in 3 days.
Use of non-comedogenic moisturizers is recommended (Sebamed clear
Gel, Cetaphil cream).
Patients are advised to wear sun protection for several weeks after their
treatment to reduce the risk of hyperpigmentation. A useful option is to
use a depigmenting cream with a sunscreen
In Indian skin, it is advisable to start a lightening cream after 7 days,
though others wait till 21 days by which time PIH appears. A nonsteroidal non-HQ based cream is preferred (MelaglowTM, Clearz PlusTM).
PITFALLS/PEARLS
1. The response to most fractional lasers is curvilinear and delayed. This
is for the simple reason that scar remodeling takes 6-9 months.Thus
giving 8 sittings gives better results. The first two treatments yield very
little visible improvement, the next two a bit more, and the final two
show the greatest degree of change. Sometimes in patients with bad
scarring an additional two treatments help but it is advisable better
to wait for 6 months to see the maximum improvement from the first
six before deciding. This has another important implication and that
is unnecessary procedures like CROSS, subcision, dermaroller and
ascribing improvement to them can wait for at least 6 months after laser
therapy! This is as they are credited with the improvement which the
laser would have induced if enough time had elapsed post surgery.
A simple protocol is, fractional laser (6-8 sessions) followed by 6 months
of follow up which should be followed by surgical procedures. Thus an
average of one year may be required for a acne scar patient.
2. Patients with significant photodamage, sagging, and deep rhytides are
not a candidate for fractional lasers as this requires other techniques like
fillers and botox, the combination of which with lasers is strictly off label.
3. To minimize the risk of systemic toxicity from the topical anesthetics,
areas no greater than 300400cm2should be treated during each session.
In case the patient complains of agitation , anxiety, nausea and perioral
paresthesias, it indicates toxicity. A infusion of normal saline is helpful.
To avoid this problem, topical anesthesia application should be limited
to no more than 1 hour.
4. In general, in Indian skin post-inflammatory pigmentation is less
common using lower density settings, fewer passes, and longer
treatment intervals.
5. Decrease the MTZ areal density if higher energies are applied per MTZ
to keep the areal fraction of damaged skin surface constant.
BIBLIOGRAPHY
1. Bagatin E, dos Santos Guadanhim LR, Yarak S, Kamamoto CS, de Almeida FA.
Dermabrasion for acne scars during treatment with oral isotretinoin. Dermatol
Surg. 2010;36(4):483-9.
2. Picosse FR, Yarak S, Cabral NC, Bagatin E. Early chemabrasion for acne scars
after treatment with oral isotretinoin. Dermatol Surg. 2012;38(9):1521-6.doi:
10.1111/j.1524-4725.2012.02460.x.
ATLAS
Fig. 1: Overlapping of fractional laser to increase the aspect ratio and density
(Er:YAG Ascepelion 90 J/cm2). This technique can be used to target deep ice pick scars
Fig. 2: Post laser crusting that tends to fall-of in 57 days. The laser used was the
Fractional Er:YAG (Dermablate, Ascepelion)
Fig. 3: A topography of a patient with acne scar, ice pick scar (yellow circle), boxcar
scar (red circle) and rolling scar (blue circle)
Fig. 4: Follow-up photograph of the patient after 5 sessions of fractional Er:YAG with
substantial amelioration of all types of scars
Fig. 5: Intense erythema and edema immediately after using the Er:Glass. This is as
the absorption spectrum for water of the Er:Glass is less than that of Er:YAG and CO2
leading to more tissue reaction
Fig. 6: A male patient with predominantly ice pick and boxcar scars. Plan: Fractional
Er:YAG (162 J/cm2; 6 sessions). The aspect ratio of the laser was altered to increase
the energy in the areas with deep scars
Fig. 7: At 6 months follow-up there is a improvement of most of the scars except

the deep boxcar scars which remodel with time, thus unnecessary surgical/TCA is
unwarranted
Fig. 8: A case with predominantly rolling scars. Plan: Fractional Er:YAG (126 J/cm2;
6sessions)
Fig. 9: Marked improvement in rolling scars which respond to most fractional lasers
Chapter
Vascular Lasers
Sujay Khandpur, Banwari Jangid
Background
Cutaneous vascular lesions, especially those occurring on the face, produce
devastating cosmetic impact and psychological distress, besides being
associated with pain, bleeding, ulceration, infection and obstruction of vital
functions. This necessitates prompt treatment with good cosmetic results.
Earlier, vascular lesions were treated with radiation, cryotherapy, excision
and grafting, and camouflage, with unsatisfactory results and poor aesthetic
outcomes. Bleeding, scarring and pyogenic granuloma formation were
the common complications. The introduction of lasers with the immense
convenience of being used in an outpatient setting, has allowed for easier
patient access with more reliable and cosmetically pleasing results. The
best therapy consists of use of the most appropriate laser that produces
significant clearance of the lesion in the fewest treatment sessions with the
least morbidity.
Laser treatment for cutaneous vascular lesions was initiated by DrLeon
Goldman in 1963 at the Childrens Hospital Research Foundation in
Cincinnati, Ohio, with the treatment of port-wine stains (PWS) and cavernous
hemangiomas using ruby, neodymium:yttrium-aluminum-garnet (Nd:YAG),
and argon lasers.
The treatment of vascular lesions is one of the most commonly requested
cutaneous laser procedures. Since the introduction of the argon laser, a
variety of laser and light sources are being used for the treatment of vascular
lesions. These include visible and infrared lasers, as well as broadband light
sources. The chromophore for treating vascular lesions is hemoglobin, whose
absorption maximum lies at 418 nm, 542 nm, and 577 nm. Therefore, lasers
with wavelengths between 488 nm and 600 nm are useful for the treatment of
vascular lesions.
Theory of Selective Photothermolysis

The theory of selective photothermolysis was developed by Anderson and Parish
(Anderson RR et al.). They proposed that, to limit thermal damage to the intended
target, the pulse duration of laser must be shorter than the thermal relaxation
Vascular Lasers 237
time of the target tissue. The thermal relaxation time of tissue is defined as the
time taken by target tissue to transfer its 50% heat to the surrounding tissue
through thermal diffusion. The thermal relaxation time of vessels with diameter
of 10 m to 50 m is 0.048 ms to 1.2 ms (Anderson RR et al.). Typical natural
chromophores in skin include water, melanin, hemoglobin, protein, lipid, etc.
Artificial chromophores that can be used include dyes, ink, carbon particles, etc.
In vascular lesions, the targeted structure is oxyhemoglobin within blood vessels.
When hemoglobin is heated, it also heats up and destroys the endothelial cells of
blood vessel walls.
Lasers Commonly Used to Treat Vascular Lesions

Flashlamp-pumped Pulsed Dye Lasers
Flashlamp-pumped Pulsed Dye Lasers (PDL) were first successfully used
by Tan et al. in 1989 for PWSs. PDL was the first laser developed based on
the principle of selective photothermolysis. The flashlamp-pumped PDL
has as its active medium an organic dye energized by a short pulse of light
from a flashlamp. PDL emits a pulsed beam of yellow light at 585 nm to 600
nm powered by flash lamp. Majority of the PDLs have an integrated cooling
system, and with maximal achievable energy fluence of 20 J/cm2 which targets
oxidized hemoglobin in superficial blood vessels. The brief pulse duration of
300 s to 500 s can cause vascular rupture. After treatment, there are
histologic findings of agglutinated red blood cells, fibrin, and platelet thrombi
within the vessels of the papillary and superficial reticular dermis (average
depth of 1.2 mm) with little or no damage to the surrounding tissue.
Neodymium:Yttrium-Aluminum-Garnet (Nd:YAG) Laser

The 1,064 nm wavelength has been used for various pigmentary diseases and
vascular dermatoses. With the advent of lasers capable of achieving longer
pulse durations and longer wavelengths, deeper (depth of 5 mm to 6 mm)
and larger caliber vessels can be treated more effectively with fewer treatment
sessions and less purpura.
The absorption coefficient of blood at 1,064 nm is 0.4/mm, which is
much higher than that of the surrounding dermis (0.05/mm) at the same
wavelength. This difference in absorption coefficients provides treatment
selectivity of deeper blood vessels. Lower absolute values of blood absorption
at 1,064 nm may be compensated by increasing the fluence. The increase in
fluence does not necessarily damage the epidermis, because the absolute
absorption of melanin is lower at 1,064 nm.
Potassium Titanyl Phosphate (KTP) Laser

KTP with a wavelength of 532 nm is an alternative laser for superficial
cutaneous vascular lesions. This laser emits green light and produces pulse
durations ranging from 1 to 100 ms. These longer pulse durations gradually
heat the blood vessel, without vessel wall rupture and subsequent purpura.
Side-effects frequently seen with the KTP are edema, crusting and atrophic
scarring (particularly using smaller spot sizes to treat nasal telangiectasias).
Because of the shorter wavelength, there is greater absorption by epidermal
melanin in darker skin types and this limits the lasers use in Fitzpatrick skin
types III-VI.
Argon Lasers
The development of the argon laser with wavelengths between 488 nm and
577 nm allowed successful treatment of vascular lesions. However, it carries
the disadvantage of damaging the surrounding tissue including epidermis,
which produces depigmentation, epidermal atrophy and scarring.
Intense Pulsed Noncoherent Light

Intense pulsed light (IPL) systems generate pulsed, polychromatic, noncoherent high-intensity light in a broad wavelength spectrum, in the range of
500 nm to 1400 nm with the use of flashlamps and cut-off filters. Depending
on the cut-off filter used, treatment of superficial or deeper vascular lesions
such as facial telangiectasias, diffuse redness, poikiloderma of Civatte, portwine stains, hemangiomas and leg veins can be facilitated.
Indications for Vascular lasers

Congential vascular lesions
Port-wine stains (nevus flammeus)
Hemangioma
Acquired vascular alterations
Rosacea
Facial telangiectasia
Telangiectasias associated with other conditions
Poikiloderma of Civatte
Angiofibroma
Blue rubber bleb nevus syndrome
Campbell de Morgan angiomas
Cutaneous lesions of Kaposi sarcoma
Pyogenic granuloma
Leg veins
Morbus Ossler (hereditary hemorrhagic telangiectasia)
Nevus araneus (spider angioma)
Senile angioma (ruby dot)
Venous angiomas
Venous lake
Vascular Lasers 239
Other skin diseases with vascular alternations

Acne
Early immature striae distensae
Inflammatory linear verrucous epidermal nevus
Psoriasis
Red or hypertrophic scars
Viral warts
Xanthelasma palpebrarum.
Port-wine stain
Port-wine stains (PWSs) are the commonest cutaneous vascular
malformations, involving the postcapillary venules, and affect 3 children per
1,000 live births with no gender predilection. It is believed that PWSs develop
within the first 2 to 8 weeks of gestation (Schneider BV et al.), appear as flat
and pink-red to violaceous patches and later turn dark purple in color. They
are present for life and have no tendency toward involution. The subsequent
hypertrophy of underlying bone and soft tissue further disfigures the facial
features of many patients. PWSs may be localized, segmental, diffuse or
extensive and occur anywhere on the body, but commonly involve the head
and neck region, classically following the trigeminal nerve distribution on the
face.
The cause of PWS still remains obscure. It is characterized by ectatic
papillary dermal capillaries and postcapillary venules in the papillary and
upper reticular dermis, with some evidence of increased vessel density but
no proliferation of vessels. The most likely hypothesis for the development
of PWS is the deficiency or absence of perivascular nervous tissue in lesional
skin, suggesting that inadequate innervation may in part be responsible for
decreased vascular tone causing permanent vascular dilatation (Smoller BR
et al.).
Vascular endothelial growth factor (VEGF) and VEGF-R2 expression
are significantly increased in capillary malformation skin tissue, suggesting
that VEGF and VEGF-R could contribute to the pathogenesis of capillary
malformations by inducing vessel proliferation (Vural E et al.). PWSs are
associated with syndromes such as Sturge-Weber syndrome, KlippelTrenaunay syndrome, Cobb syndrome and Proteus syndrome.
Infantile hemangioma
Hemangiomas affect up to 4% to 10% of infants, with 60% occurring on the
head and neck, 25% on the trunk, and 15% on the extremities (Finn MC et al.).
Eighty percent of hemangiomas are single, well-circumscribed lesions,
0.5 cm to 5.0 cm in diameter, while the rest are multiple, cutaneous and
visceral lesions (Mulliken JB).
Infantile hemangiomas present at birth or in neonatal period, as small

macule or patch of erythema which later rapidly proliferate, then stabilize,
and slowly involute. The course of individual hemangiomas is heterogeneous,
making it difficult to predict outcomes reliably. Approximately 20% of
hemangiomas may develop complications in form of ulceration, bleeding,
infection, functional impairment with visual, feeding and respiratory
difficulties, which may require active intervention. Fifty percent of infantile
hemangiomas completely involute by age of 5 years and 90% by 9 years of
age. The remainder may take additional 24 years to complete the process
(Bowers RE et al).
They can be classified as superficial, deep and mixed hemangiomas.
Superficial lesions are raised and bright red, and upon regression, leave a
flaccid, pedunculated, waxy, yellow-colored skin. Deeper dermal lesions
appear as bluish subcutaneous nodules with overlying skin having a fine
network of telangiectasia and resolve leaving smooth skin surface with
overlying telangiectasia.
According to a study, the lesions that involuted by age 6 years had 38%
residual evidence and hemangiomas that completely involuted after age 6
years exhibited cutaneous residua in 80% instances including scar formation,
telangiectasia, or redundant skin (Finn MC et al.). Hence it has been shown
that infantile hemangiomas that take longer to involute have a higher
incidence of residual changes.
Common acquired vascular lesions

Rosacea
Rosacea is a chronic disorder involving the mid facial region and occasionally
the neck, scalp and eyes. It usually occurs between 20 and 50 years, with
female preponderance, however, men more frequently progress to the
end stages of severe rosacea. Clinically, rosacea can be classified into four
subtypes- erythematotelangiectatic, papulopustular, phymatous and ocular
rosacea, with one variant, granulomatous rosacea.
Rosacea Staging
Stage
I

II

III

Symptoms and Signs

Pre-rosacea
Frequent flushing/blushing
Easy irritation and erythema of facial skin
Vascular stage
Transitory erythema of midfacial areas
Early telangiectasias
Deeper facial erythema
Increased telangiectasias
Papule and pustule formation
Vascular Lasers 241
IV
Tissue hyperplasia
Rhinophyma

Possible ocular inflammation
The first stage of rosacea is merely a vascular hyper-reactivity or tendency
for the central face to redden easily. The early stage of rocasea is difficult to
treat, except for avoiding the triggering factors. Second stage of rosacea is
characterized by persistent and progressive erythema and ocular symptoms.
Papules, pustules and telangiectasias develop when the disease progresses to
third stage, finally, the fourth stage is characterized by rhinophyma, in which
soft tissue hypertrophy of nose occurs producing a red, bulbous nose.
Erythematotelangiectatic rosacea have been successfully treated with
PDL. In addition to PDL, other lasers, including potassium titanyl phosphate,
532 nm Nd:YAG, 1064 nm Nd:YAG, argon, copper-bromide, and intense
pulsed light have been used in treatment of facial telangiectasia.
Other Facial Telangiectasia

Besides rosacea, facial telangiectasias are seen in hereditary hemorrhagic telangiectasia, collagen vascular diseases, idiopathic generalized telangiectasia
and unilateral nevoid telangiectasia.
Poikiloderma of Civatte
Poikilodermatous skin is characterized by atrophy, hyper- and hypo
pigmentation, and telangiectasia. Poikiloderma of Civatte occurs on the sides
of neck, more commonly in middle-aged women with a fair complexion.
Several lasers have been tried including argon, potassium titanyl phosphate
(KTP), pulsed dye laser and intense pulsed light devices with variable results
(Goldman et al.; Oldbricht et al.; Batta K et al.; Wheel and RG et al.; Clark RE
et al.). Multiple sessions are usually necessary to obtain optimal clearance.
Venous Lakes
Venous lake is usually a solitary, soft, compressible, dark blue to violaceous,
0.2 cm to 1 cm sized papule caused by dilatation of venules. These are
commonly found on sun-exposed surfaces of the vermilion border of lip, face
and ears. Lesions generally occur in the elderly. Venous lakes have clinical
importance because of their mimicry to malignant lesions, such as melanoma
and pigmented basal cell carcinoma. Various surgical and laser modalities
have been tried for venous lakes.
Varicose veins
Varicose veins are dilated, tortuous, palpable subcutaneous veins, generally
larger than 3 mm in diameter, most commonly found in the legs. Visible
varicose veins in the lower limbs are estimated to affect at least a third of the
population. According to a study, 29% of those who had visible varicose veins
without complications progressed to serious venous disease after 6.6 years

(Rabe E). In another study, approximately 36% of people developed varicose
ulcer in their life (Nelzen O).

Patient Selection
Appropriate treatment of vascular lesions begins with a correct diagnosis. A
misdiagnosis can lead to ineffective and potentially harmful treatment. Proper
patient selection is mandatory for good success rates. Patients presenting for
treatment with vascular lasers are treated with the following goals:
1. Improving overall appearance, with an ideal target to clear the lesions
without any complications
2. Improvement in functionality
3. Prevention of disfigurement
4. Avoiding aggressive procedures
5. Preventing or treating ulcerated lesions
6. Minimizing psychological distress.
Preoperative
A written informed consent of the patient is taken
Patients are scanned for unrealistic expectations. Doctor or staff
should always explain about the procedure to the patient. Multiple
laser treatments are usually necessary to remove a vascular lesion
necessitating multiple sessions at regular intervals. Although laser
treatment has fewer side-effects as compared to surgical procedure,
there is a small risk of the following which needs to be explained to the
patient: Hypopigmentation, hyperpigmentation, mottled discoloration,
infection, pain, swelling, activation of herpes simplex infection, allergic
reaction to local medications, atrophy or mild scarring, and lesion
persistence despite treatment
Baseline and subsequent pre-session photographs are taken
Laser treatment is usually well-tolerated. Topical anesthetics (such as
2.5% lignocaine + 2.5% prilocaine) should be applied under occlusion
for at least 45 minutes before the procedure to reduce local discomfort
The area to be treated should be shaved in the morning of treatment
and rinsed well. No hair removing creams or lotions should be used. No
creams, lotions or sprays should be applied to the area
The area being treated should be cleansed with mild soap and alcohol.
Intraoperative
The correct laser parameters are chosen and recorded
Vascular Lasers 243
Laser safety of the doctor and patient is ensured by wearing especially

designed protective goggles during the procedure
A test shot is given before procedure to check for any significant pain
The patient is advised not to move his head or flinch with each pulse of
light delivered as the machine makes a popping sound
The laser is delivered concomitantly with cryogen cooling to prevent
nonspecific thermal damage to surrounding tissue.
Postoperative
Immediately after procedure, the patient is advised to apply cold
compresses to the treated site
A topical steroid-antibiotic cream is applied
The patient is explained about immediate post-treatment appearance.
After treatment, the area may be discolored (purpura) and swollen.
Following this, a blister and/or crust may form which can last up to 714
days. To reduce swelling and discomfort, cool water compresses may be
applied to the area. Do not apply ice directly to the treated area
The rate of response to treatment is explained
In case of pain and discomfort, acetaminophen is preferred over aspirin
or ibuprofen during the healing phase (1 to 2 weeks) as this can increase
bruising
Showers are permitted but prolonged hot baths are not advised for 12
weeks. Patients are advised not to rub but dab the treated area with a
towel because the area is extremely delicate while healing
Make-up and moisturizers may be applied as usual if there is no blister/
ulceration. Otherwise, wait until the crusting has come off. If make-up is
applied to cover up the bruising, do not use make-up remover or cleanse
harshly while the skin is still healing as this may injure or abrade the
treated area
Avoid sunlight exposure to the treated areas. Use a sunscreen with SPF
30 or higher for several months following treatment to avoid prolonged
redness or pigmentary changes
Avoid swimming and contact sports while the skin is healing
Post-treatment precautions: Patients should avoid:

a. Exercise for three days after treatment

b. Consumption of alcohol or any blood thinners for five days

c. Taking hot showers or baths, use of hot tubs or saunas for five days
The subsequent sessions should be undertaken at 68 weeks interval.
Prior to the next session, thoroughly examine the treated site and
compare with baseline photograph to look for improvement and sideeffects following previous therapy in order to decide the next laser
parameter.
Pearls and Pitfalls

1. Port-wine Stains
PDL was specifically designed to treat small vessels found in childhood PWSs.
Controversy exists about treating PWS in early versus late stage. However,
there are certain advantages of early treatment:
In early stage, the lesion is small in size so fewer spots and sessions are
required
Resolution is quick as compared to older lesions, so fewer treatments
are required (Alster TS et al.)
Early clearance produces less psychological effect on child (Lanigan
SW).
Morelli and Weston (Morelli JG et al.) demonstrated that early treatment
of PWS gives better results. They proposed that therapy can be started as early
as 7 to 14 days of age and three treatments may be undertaken before the
infant reaches 6 months of age. They noted a 50% resolution with this protocol
by the third treatment. In another study, Goldman et al. treated 43 children
with 49 lesions of capillary malformation between ages of 2 weeks and 14
years. A total of 28 lesions treated in children under age 4 years had greater
overall improvement with less treatment sessions as compared to those over
age 4.5 years (Goldman MP et al.). Alster and Wilson reported 87% clearance
rate in patients less than 2 years of age, 78% clearance in those aged 3 years
to 8 years, and 73% clearance in patients 16 years and older. All these studies
demonstrate a better treatment outcome in younger patients (Alster TS et
al.). Nguyen CM et al. evaluated the predictors of improvement of PWS and
proposed that younger patients with small PWS (less than 20 cm2) that are
located over bony areas of the face, show greater response when compared to
others (Nguyen CM et al.).
The common starting parameters are fluence of 5.05.5 J/cm2, with
increase by 0.5 J/cm2 with each subsequent treatment, using a 7 mm-diameter
spot size. In our experience, 5 to 10 sessions are required to achieve significant
improvement/clearance. Superficial lesions clear more quickly, with around
four sessions, reaching a level of 95% clearance (Goldman MP et al.). When
compared with adult PWS, in children, a lower fluence and larger spot size is
recommended. Larger spot size prevents cobble stone appearance.

With regard to the number of sittings required for complete or near
complete clearance, Koster PHL et al. proposed a mathematical factor of
10% clearance with each session for the first five or six treatments. Additional
treatments result in lesser therapeutic response so that 20 treatments are
required to produce 90% clearance. Lesions present on the lateral side of
forehead and cheeks, proximal part of arms and chest respond better as
compared to central area of face and limbs (Alster TS et al.).
Vascular Lasers 245
Adverse events are usually temporary and include purpura and epidermal
crusting. Purpura is more common with PDL compared to other lasers and
IP lights. The most common long-term sequelae are pigmentary changes
since melanin is a competitive chromophore with hemoglobin in patients
with higher Fitzpatrick skin types. Other less common complications are
checkerboard pigmentation, hypopigmentation, atrophic and hypertrophic
scarring and keloid formation. According to a study, discoloration and
purpura were seen in almost all patients, crusting in 52%, and scaling or
peeling in 19.6% cases (Ruiz-Esparza J et al.).
Factors Affecting Treatment Response

Site of lesionlesions over the face, and trunk respond better than legs
(Alster TS et al.)
Size of lesionlesions larger than 20 cm2 respond poorer as compared
to smaller lesions (Nguyen CM et al.)
Color of lesiondark red and purple PWS are less responsive than pink
or red lesions. The purple color of lesion indirectly reflects the depth of
lesion (Ruiz-Esparza J et al.).
Skin typesfairer skin types respond better than dark skin (Sharma VK
et al.; Ernest Tan et al.)
Depth of lesionlesions with deeper vessels respond poorly. PDL at
585 nm and 6 to 8 J/cm2 have been found to coagulate the vessels up to
0.65 mm (mean 0.37 mm). 585 nm dye is more effective in pink or red
PWS whereas blue or dark red PWS respond well with 595 nm dyes
(Figs 5.1 to 5.4).
In our practice, for treating PWS with the 595 nm PDL, the laser
parameters that we use are a spot size of 7 mm, starting fluence of 78
J/cm2 with increase up to 12 J/cm2 (for hypertrophic PWS) and pulse
durations ranging from 0.456 ms.
If the PWS are not responding to PDL:
Use higher fluences, increase the spot size of the PDL
Change from a 585 nm to a 595 nm wavelength (Chang CJ et al.; GreveB
et al.)
Increase the pulse duration from 0.45 ms to 1.520 ms (Greve B et al.)
Perform multiple passes at the same session with variable pulse
durations
Combination of lasers: 595 nm and 1,064 nm laser, PDL and diode laser
(Alster TS et al.).
Argon Laser in PWS

Argon laser was the first to be used for vascular malformations. It is useful for
treating hypertrophic nodules of very thick PWS (Dixon JA et al.).
Figs 5.1A and B: (A) Pretreatment image of PWS over right face; (B) 80% clearance
after 7 sessions of 595 nm PDL
Figs 5.2A and B: (A) Pretreatment image of PWS over left paranasal region; (B) 90%
clearance after 10 sessions of 595 nm PDL
2. Lasers in Hemangiomas
The argon laser has been effectively used to treat hemangiomas. The potential
drawbacks of argon laser are its depth of penetration into the dermis (<1
mm) and its tendency to cause hypertrophic scarring by nonspecific thermal
injury. In one study, children under age 12 years were treated with argon
laser and the results were poor in more than 50% cases, therefore, author do
Vascular Lasers 247
Figs 5.3A and B: (A) Pretreatment image of PWS over right face; (B) More than 90%
(Courtesy: Sharma VK, Khandpur S. Efficacy of pulsed dye laser in facial portwine stains in Indian
patients. Dermatol Surg. 2007;33(5):560-6)
Figs 5.4A and B: (A) Pretreatment image of PWS over left face and neck; (B) 90%
(Courtesy: Sharma VK, Khandpur S. Efficacy of pulsed dye laser in facial portwine stains in
Indian patients. Dermatol Surg. 2007;33(5):560-6)
not recommend argon laser treatment in children under the age of 12, except
for infants with complications of capillary hemangiomas (Smith JD).
The Nd:YAG laser, with 1,064 nm wavelength can penetrate into deeper
dermis (up to 8 mm) but produces widespread tissue injury and scar
formation by its nonspecific absorption (Apfelberg DB et al.). The tissue
injury can be minimized by using 34 mm diameter spot size with 68 mm
untreated area between spots.
Preeyanont et al. on treating 160 patients with the Nd :YAG laser at fluences
of 400 to 1600 J/cm2 and pulse durations of 0.5 second, found excellent results
in 13% cases, 55% had a reduction in hemangioma size by more than 50%,
35% had less than 50%, reduction in lesion size and 2% had poor response.
Ten percent of patients developed scarring (Preeyanont P et al.).
KTP is an intralesional laser in which the laser fiber is passed through
a needle that is positioned in the center of the hemangioma and then laser
energy is delivered. The end point of therapy is shrinkage of overlying skin
that later becomes warm to touch. KTP laser is indicated for voluminous or
large hemangiomas where deeper penetration with conventional lasers is not
possible, although it has higher chance of scar formation.
The long-pulse PDL, with a wavelength of 595 nm has proven effective
in the treatment of superficial (macular) and ulcerated hemangiomas. A
retrospective analysis of 60 pediatric patients conducted by Kim et al. showed
that in 37% of ulcerated hemangiomas treated with PDL, 50% showed definite
improvement, 18% showed no response and 5% showed worsening of
lesions (Kim HJ et al.). Morelli and Weston concluded that ulcerated painful
hemangiomas are the best indication for PDL (Morelli JG et al.).
Various studies confirm the efficacy of PDL in early hemangiomas.
Most authors report cessation of the proliferative phase as a consequence
of treatment with the PDL (Glassberd E et al.; Sherwood KA et al; Garden
(JM et al.). Maier et al. treated 100 hemangiomas within 12 weeks of their
development and found that 73 lesions required a single treatment and 27 up
to five treatments; 23% of lesions showed complete remission, 55% showed
partial remission, and 14% stopped growing. Only 8% of lesions continued to
grow despite treatment (Maier H et al.).
PDL is also useful in treating residual telangiectasia following spontaneous
resolution of hemangiomas, for improving cosmetic results.
A combined therapy of medical management, debulking surgery and
PDL has been used in treatment of large or extensive hemangiomatosis
and shown faster resolution of infantile hemangiomas. Studies have shown
better response of infantile hemangiomas when medical management was
combined with PDL as compared to medical therapy alone. Poetke et al in
their prospective, observational study of large facial hemangiomas on 23
patients with age ranging from 2 months to 3.5 years, of which 14 patients
received propranolol in combination with laser therapy, reported that
only one case receiving the combination therapy experienced rebound
Vascular Lasers 249
hemangioma growth. Nine patients were treated with propranolol (2 mg/kg

per day) alone and six had rebound growth when treatment was stopped.
This study suggests that propranolol plus PDL may be more effective than
propranolol alone.
The Nd:YAG laser at 1,064 nm can penetrate deeper into tissue (28 mm)
but produces widespread tissue injury because of its nonspecific absorption.
This tends to result in scar formation.
Carbon dioxide laser is also useful as a debulking tool for large
hemangiomas, oral hemangiomas and laryngeal lesions producing airway
obstruction. Scarring is significant so it is usually not recommended for facial
hemangiomas.
IPL with a cut-off filter at 550 nm, 570 nm or 590 nm has shown excellent
results for multiple hemangiomas. Foster and Gold treated an ulcerated
cavernous hemangioma in an 11 week old black infant with setting of 550 nm
cut-off filter at a fluence of 38 J/cm2 resulting in 90% involution (Foster TD et
al.).
Treatment of hemangiomas should be decided on the basis of individual
circumstances such as the size and location of the tumor, complications, the
phase at the time of evaluation, involvement of other organs and psychological
factors.
3. Telangiectasias
Telangiectasia is a clinical entity of superficial dilated venules, capillaries or
arterioles with average diameter of 0.1 mm to 1.0 mm. Telangiectasias that
are arteriolar in origin have a smaller diameter, are bright red in color and do
not protrude above the skin surface. Those that arise from venules are wider,
blue in color and often protrude above skin surface.
Telangiectasia have been subdivided into four types, based on clinical
appearance (Redisch W et al.):
1. Simple or linear
2. Arborizing
3. Apider
4. Papular.
Telangiectasias can be treated with PDL using 3, 5, 7 or 10 mm spot size,
fluences ranging from 5 to 8 J/cm2 with a 0.45 ms pulse duration or higher.
Purpura can be minimized by giving two to three pulses over the telangiectasia
at lower fluences (pulse stacking), using spot size 10 mm diameter at 45 J/cm2
and undertaking therapy with the 595 nm PDL as compared to 585 nm.
Conclusion
There are multiple vascular disorders that can be treated by laser, with varying
degree of efficacy. An overview of the common disorders were discussed here
while other disorder are discussed. (See Chapter 12).
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Chapter
Lasers for Hair Removal

Soni Nanda, Shikha Bansal, Kabir Sardana
INTRODUCTION
Laser hair reduction (LHR) has proved to be a safe and effective means of
getting rid of unwanted hair.
The term permanent hair reduction is more appropriate and informative
than the term permanent hair removal.
Different laser systems including the alexandrite, ruby, diode, and
neodymium-doped: yttrium aluminum garnet (Nd:YAG) and now intense
pulsed light (IPL) have been tried in all skin types. It is one of the most
commonly done cosmetic procedures. It is performed by a whole range of
people: by the patient at home, beauty salons, technicians and dermatologists.
The results vary according to technique, expertize and the machine employed.
If LHR is done for the correct indication, with proper laser machine, with right
fluence and pulse width, it can be quite rewarding for the patient.
History of lasers for hair reduction: Variety of lasers are now available to
successfully reduce unwanted hair. Ruby lasers were the first to be applied;
however, there is now a wide array of lasers including alexandrite, diode and
Nd: YAG as well as a variety of broad spectrum IPL devices. Hair removal lasers
have been in use since 1997 and have been approved for permanent hair
reduction in the United States by the Food and Drug Administration (FDA).
Under the FDAs definition, permanent hair reduction is the long-term,
stable reduction in the number of hair regrowing after a treatment regime.
Indeed, many patients experience complete regrowth of hair on their treated
areas in the years following their last treatment. This means that although
laser treatments with these devices will permanently reduce the total number
of body hair, they will not result in a permanent removal of all hair.
Improvements in lasers since 1997, in terms of more effective means of
epidermal cooling and ergonomically-designed handpieces, have made
treatment more tolerable for both patient and operator and reduced the
chances of side effects. On going clinical research has led to more optimized
treatment parameters, but understanding of lasers and their long-term effects
on hair and other skin structures are still in the early stages.
Lasers for Hair Removal 253
In 2008, two manufacturers launched FDA-approved laser hair removal

devices for at-home use that are compact and portable. Ever since, many
more such devices have been launched in the market. These are low energy
devices. Eye protection remains a major area of concern for these home use
devices.
Relevant Basics of Hair Anatomy and Physiology

Each hair follicle consists of a permanent (upper) and nonpermanent
(lower) part, with the follicular bulge forming the lowermost aspect of the
permanent part. In periods of active growth (anagen), the rapidly developing
bulbar matrix cells differentiate into the hair shaft and the hair lengthens. A
transition period follows in which the bulbar part of the hair follicle undergoes
degradation through apoptosis (catagen). A resting period (telogen phase)
ensues, and regrowth is started once again in early anagen.
Hair Growth Cycle

The hair contain melanin only in anagen phase of development and thus are
susceptible to injury. During a particular point of time, not all hair are in anagen
phase, hence multiple treatments are necessary to treat all the hair follicles. Laser
works on the hair in the anagen phase. The spacing between the sessions is done
on the basis of the hair cycle of that particular area (Table 6.1).
Adult hair are of two types: Vellus and terminal. Vellus hair can be found over
the entire body and appear as soft, fine, short hair that are non-pigmented
or light pigmented. Terminal hair are coarse, long and dark present on scalp,
under arms, eyebrow, beard, chest and pubic region. Terminal hair are ones
which respond to laser therapy.
Table 6.1 Regional variation in the percentage of hair in the anagen phase
Body area
% Telogen hair
% Anagen hair
Telogen
duration
Follicles density Depth of

(1/cm2)
follicle
Scalp
13
85
34 months
350
35 mm
Beard
30
70
10 weeks
500
24 mm
Upper lip
35
65
6 weeks
500
12.5 mm
Axillae
70
30
3 months
Trunk
65
3.54.5 mm
70
24.5 mm
3.54.5 mm
Pubic area
70
30
12 weeks
70
Arms
80
20
18 weeks
80
Legs and
thighs
80
20
24 weeks
60
2.54 mm
Breasts
70
30
65
34.5 mm
Classification of Excess Hair

Excessive and unwanted body hair range in severity and can usually be
classified as either hypertrichosis or hirsutism.
Hirsutism is defined as the abnormal growth of terminal hair in women in
male-pattern (androgen-dependent sites), such as the face and chest.
Hypertrichosis refers to excess hair growth at any body site that is not
androgen-dependent.
Basic principleS of Laser Hair Reduction

Selective Photothermolysis
The target of the lasers for hair reduction is the stem cells in the bulge and
bulb area of the unwanted hair. The concept of selective photothermolysis
introduced by Parish and Anderson in the 1980s redefined the way in which
lasers are performed. The laser light is given at such intensity to damage
the target melanin, i.e. the melanin in the hair follicle without affecting the
melanin in the adjoining skin. To achieve this, the pulse width or the duration
in which the light is delivered has to be less than or equal to the thermal
relaxation time of the hair follicle.
Ideal Wavelength
Melanin absorbs light broadly across the optical spectrum ranging from
2501200 nm. In wavelengths less than 690 nm oxyhemoglobin becomes
a strong competing chromophore and above 1000 nm, affinity of light for
water increases significantly. Hence, 6901000 nm becomes the optimum
wavelength for lasers targeting melanin in hair follicles. While melanin affinity
for light is higher at 690 nm, safety becomes an issue at such low wavelengths,
especially in dark skinned individuals as the epidermal melanin also has a
high probability of absorbing light and causing burns. Longer wavelengths
have deeper penetration, hence these reach the bulb and bulge area of the
hair and are safe even in dark skinned individuals. Hence the wavelengths
ranging from 800 nm to 1000 nm are considered optimum for hair reduction
in dark skinned individuals.
Photothermal destruction of hair follicles is based on the concept of
selective photothermolysis. Selective photothermolysis states that selective
thermal damage to a pigmented target structure will occur when a specic
wavelength is delivered at a sufcient uence level during a time equal to
or less than the thermal relaxation time (TRT) of the target. Applying the
principle of selective photothermolysis to hair removal means that laser and
IPL procedures are dependent on the presence of melanin in the hair shaft,
since melanin is the target chromophore that absorbs energy from specic
wavelengths, resulting in spatially conned thermal damage to melanin-
containing structures when pulse durations correspond to the TRT. However,

recent evidence suggests that the goal of laser hair removal is to damage cells
in the of the outer root sheath, which requires diffusion of heat from melanin
in the hair shaft.
Thus the concept of thermal damage time (TDT) has, therefore, been
introduced for hair removal wherein pulse durations are longer than the TRT,
allowing dissipation of thermal damage to the follicular stem cells.
Selecting Important Parameters

Wavelength
Shorter wavelengths are absorbed more strongly by melanin than longer
wavelengths. Longer wavelengths penetrate deeper and are safer to use in
individuals with darker skin types. Accordingly, shorter wavelengths can be
used for patients with fair skin types and longer wavelengths for patients with
darker skin types at the risk of adverse effects .
Thus a wavelength ranging from 600 to 1000 nm of the electromagnetic
spectrum can penetrate to the appropriate depth of the dermis (up to
24 mm) and cause selective photothermolysis of the target chromophore,
which is the melanin pigment of hair follicle.
Pulse duration
TRT of human terminal hair follicles is estimated to vary between 10 and
100 ms, depending on the size of the hair. The ideal pulse duration should
be longer than the TRT for the epidermis (310 ms) and adjusted to the TRT/
TDT for hair follicles. Devices for hair removal, therefore, operate with pulse
durations in the long millisecond range, and the pulse durations between
10 and 50 ms is optimal to target hair follicles. Super long pulse heating
(>100 ms) may allow for long-term hair removal.
Fluence
Optimum fluence or energy is such which would cause effective thermal
destruction of the hair follicle melanin without causing any damage to the
epidermis. This would be different for different individuals depending on the
skin and hair type. The best way to decide this is to do a patch test with three
different fluences and then deciding the right fluence depending on the skin
response. This is the most important parameter responsible for longterm
reduction achieved with lasers. Highest tolerable fluence gives better results
by causing effective thermal destruction of hair follicle melanin in the dermis
but heat damage to the epidermal melanin, which may result in adverse
effects of burns, blistering, dyspigmentation and scarring, especially in dark
skinned patients.
Spot size
A small spot size is useful for doing small areas like upper lips, side locks, etc.
A larger spot size has better penetration and is more comfortable and quick
for large body parts. Larger the spot size of the laser beam, deeper and more
even is the penetration.
Skin cooling
This is one aspect of lasers and light devices which is being constantly
improved. Adequate skin cooling significantly increases the patient comfort,
decreases the chances of burns and improves the results as higher energy
levels can be delivered to the patient safely.
Cooling Mechanism
Cooling can be obtained before, during, and after laser treatment (pre-,
parallel level, and post-cooling) as contact cooling (cooled sapphire, metal
or glass plates integrated into the handpiece, cooled gel layer); cold air
ventilation; and dynamic cooling devices when pulsed cryogen spray is used
as a cooling agent .
The least effective type of cooling is the use of an aqueous cold gel, which
passively extracts heat from the skin and then is not capable of further skin
cooling. Alternatively, cooling with forced chilled air can provide cooling to the
skin before, during, and after a laser pulse. Currently, most of the available LHR
devices have a built-in skin cooling system, which consists of either contact
cooling or dynamic cooling with a cryogen spray. Contact cooling, usually
with a sapphire tip, provides skin cooling just before and during a laser pulse.
It is most useful for treatments with longer pulse durations (>10 ms). Dynamic
cooling with cryogen liquid spray pre-cools the skin with a millisecond spray of
cryogen just before the laser pulse. A second spray can be delivered just after
the laser pulse for post-cooling, but parallel cooling during the laser pulse is not
possible as the cryogen spray interferes with the laser beam. Dynamic cooling
is best suited for use with pulse durations shorter than 5 ms.
The various method of cooling include:
Cryogen sprays: These are more useful when working with low pulse width
lasers.
Chill tip cooling: This is now seen in majority of the lasers. The temperature
of chill tip is 4 degrees before and after shot and 0 degree during the shot. This
is a very practical and convenient means of pre- and post- and cooling during
the session.
Ice packs: These can be used for post-cooling while doing large body parts
and also with the laser/light machines which dont come with the option of
chill-tip cooling. Using of ice packs can be very cumbersome at times and are
at best adjunctive measure.
Forced refrigerated air (Zimmer): This is now gaining popularity as means
of cooling with all laser procedures including the laser hair reduction. It gives
chilled air and can be used throughout the procedure to increase the patient
comfort.
Indications of Laser Hair Reduction

1. Unwanted body hair in individuals with more than 15 years of age
(IADVL task force recommendation)
2. Hirsutism
3. For special conditionspseudofolliculitis barbae, pilonidal sinus.
An ideal patient is the one with coarse, dark, terminal hair in absence of
underlying hormonal imbalance and has realistic expectations (Figs 6.1 and
6.2).
Contraindications of Laser Hair Reduction

They can be subdivided into absolute and relative.
Absolute contraindications include Photosensitive disorders, e.g. systemic
lupus erythematosus, presence of active infection in the local area, e.g. herpes
labialis, staphylococcal infection.
Fig. 6.1: An ideal patient with dark terminal hair
Fig. 6.2: A patient with coarse thick black hair on the chin, an ideal case for laser
intervention
Relative contraindications include patients with superficial cuts and injuries

in the local area as it makes the skin more prone to laser burns, keloidal
tendency and patient with unrealistic expectations. Isotretinoin makes
the skin dry hence chances of burns increase. Also it alters the fibroblastic
response, hence healing is delayed. Hence in patients on isotretinoin, laser
should be avoided. Gap between laser and isotretinoin depends on the
dosage used. Ideally a 6 months gap is recommended if patient is on this drug
for 6 months.
Hair Removal: an Evidence-based outlook

Various studies have reported on the efcacy of different laser systems
to reduce hair growth, and reduction in the number of hair counts is the
endpoint most often evaluated. To make meaningful comparisons between
treatments, it is important to consider under which circumstances the
treatment results are reported, because huge diversities are seen in terms
of study design (randomized and nonrandomized controlled studies,
uncontrolled studies, retrospective studies, case reports); patient inclusion;
treatment settings, including specic devices; number of treatment sessions;
and follow-up periods.
To demonstrate the true effectiveness of laser and IPL devices, two
definitions can be employed:
Hair reduction estimated up to 6 months after treatment is considered
as short-term efcacy and beyond 6 months postoperatively as long-term
efcacy.
Hair Removal Devices

The current market for laser hair reduction is growing so rapidly that the
FDA has not maintained an up-to-date listing of all approved laser devices.
Currently used lasers fall into one of four categories: the long-pulsed ruby
laser (694 nm), the long-pulsed alexandrite laser (755 nm), the long-pulsed
semiconductor diode laser (800810 nm), and the long-pulsed Nd:YAG laser
(1,064 nm). Additionally, the Intense Pulsed Light (IPL) system (5151,200 nm)
is approved as a safe and effective method for hair reduction . ELOS has been
used but is not as effective as other systems.
Other devices that have not been included in the table 6.2 include
fluorescent pulse light , optical light energy combined with RF (eMax/eLight
of Syneron) and diode combined with RF (eLaser Syneron and MeDiostar
Effect Ascepelion).
Home Use Devices

They have recently gained popularity due to the low cost involved and
convenience of the patient. Home use devices have their own set of safety
concerns as they are being used by untrained professionals.

Table 6.2 Overview of some of the FDA approved devices for hair removal
Laser
Devices
Patient type
Hair reduction
Hair removal
Long-pulsed
ruby
lasers (694 nm)
E2000
Epitouch Ruby
Ruby Star
Sinon
IIII (SPT)
Hair: Dark to light
brown
Fine and coarse
3849% hair
reduction
Long-term
hair removal
Long-pulsed
alexandrite
lasers
(755 nm)
Apogee
Arion
Epicare
Epitouch ALEX
Gentelase
Ultrawave II/III
IIV (SPT)
Hair: Dark to light
brown
Fine and coarse
7478% hair
reduction
Long-term
hair removal
Pulsed diode
laser (800 nm)
Apex-800
F1 Diode Laser
LightSheer
MedioStar
SLP1000
IIV (SPT)
Hair: Dark to
light, brown and
coarse
7084% hair
reduction
Long-term
hair removal
Long-pulsed
Nd:YAG lasers
(1,064 nm)
Acclaim 7000
Athos
CoolGlide
Dualis
Gentle Yag
Lyra
Mydon
Prole
Smartepil II
Ultrawave I/II/III
Varia
Vasculight Elite
IVI (SPT)
dark and coarse
hair
2953% hair
reduction
Long-term
hair removal
Intense pulsed
light source
(5151,200 nm)
Ellipse
EpiLight
Estelux
PhotoLight
ProLite
Quadra Q4
Quantum HR
Spatouch
SpectraPulse
IVI(SPT)
Dark to light
brown and coarse
hair
4990% hair
reduction
Long-term
hair removal
Home-based devices are based on IPL and laser technologies but operate
at lower fluences than comparable in-office devices. The 810-nm diode Tria
laser (Tria Beauty, Inc, Dublin, CA) and 475 to 1,200 nm IPL Silkn device
(Home Skinovations, Kfar Saba, Israel) are the current FDA-approved home
use hair removal systems.
One safety feature on most home-use devices is a skin contact sensor that
prevents the beam from firing when not on the skin. Light is supposedly selfcontained within the device, and special protective goggles are not required,
but if eye precautions are breached, irreversible corneal burns, lens cataracts,
and retinal damage may result. Aside from ocular damage, unintentional
misuse by individuals with darker skin type or a tan or inappropriate
treatment of moles or tattoos may lead to thermal burns.
Results of LHR
Evidence for Short-term Efcacy (up to 6 Months After Epilation)
Substantial evidence exists for a short-term efcacy of hair removal up to
6 months after treatment with the ruby laser, alexandrite laser, diode laser,
Nd:YAG laser, and IPL.
The efcacy is improved when repetitive treatments are given and there
is considerable evidence that the short-term efcacy from photoepilation
is superior to conventional treatments with shaving, wax epilation, and
electrolysis.
Overall, the short-term efcacy is reported between 30% and 70% hair
reductions up to 6 months after the last treatment; the treatment outcomes
depend on the treatment settings.
Evidence for Long-term Efcacy (Beyond 6 Months After Epilation)

Evidence was found for a long-term efcacy of hair removal after repetitive
treatments with the alexandrite laser, the diode laser, and the long-pulsed
Nd:YAG laser. It may be possible that repetitive treatments with the ruby laser
(34 treatments) and IPL (5 treatments) are capable of inducing long-term
hair reduction as well, although the actual evidence is sparse.
The overall results from long-term studies with the alexandrite, diode,
and Nd:YAG laser vary a lot, but show on average a 50% hair reduction from
repetitive treatments with these devices (Table 6.2).
Procedure
Preoperative
1. Patient counseling, expectation alignment and informed consent: A
detailed consent form should be developed which should include details
regarding the procedure, the expected results and rare side effects that can
be expected with the treatment. The patient should be clearly informed in
the beginning and before every subsequent session that the laser would
give a very good delay of growth, decrease the number of hair and make the
hair finer but it will not cause removal of all the hair. The patient has to be
informed regarding the gap between the sessions (according to the body part
being treated). In between the sessions, the patient can theoretically use hair
removing creams or shave the area. The authors preferably avoid using hair
removal creams as irritant reactions are very common. The patient should also
be informed regarding the number of sessions, requirement of maintenance
sessions and the total cost of the procedure. In case any hormonal imbalances
concomitant therapy may be needed.
2. History and examination: A detailed history including age of onset of
hair growth, menstrual history, and any concomitant drug intake should be
taken. Any previous treatments taken for the same should be recorded. If
the patient is suspected to be having hirsutism due to underlying polycystic
ovarian disease, a complete work up should be done including the ultrasound
pelvis to rule out polycystic ovarian disease (PCOD) along with hormonal
profile. An endocrinological opinion can be sought for the same, if required.
Appropriate medical therapy should be initiated and patient should be
aligned regarding the more number of sessions that would be required.
Patients with an sudden onset of hypertrichosis should be evaluated for
paraneoplastic etiologies.
History of any photosensitizing drugs, colloid and hypertrophic scars,
history of recent sun exposure and tanning, parlour activities and occupations
involving prolonged exposure to sun should be recorded. Patient should
be asked regarding photosensitive conditions, such as the autoimmune
connective tissue disorders, or disorders prone to the Koebner phenomenon.
A history of recurrent cutaneous infections at or in the vicinity of treatment
area might warrant the use of prophylactic medications.
Topical retinoids used in the treatment area should be discontinued at
least 4 days prior to treatment. There are divided opinions regarding use of
oral retinoids along with laser treatment. Majority of clinicians recommend a
washout period of 6 months to one year after stopping the drug.
The patient is assessed for the Fitzpatrick skin type, as darker skin types
are more prone to adverse effects related to laser therapy, e.g. burns or postinflammatory hyperpigmentation.
Examination is done for the presence of tan. If present, the treatment
should be deferred till subsidence of tan. Tanned type 4 skin is more prone to
burns than type 5 skin.
One of the most important steps in evaluation of patient for LHR is
assessment of patients hair color. It is important as the chromophore for LHR
is melanin. Black and brown hair contain sufficient amounts of melanin to
serve as a chromophore for LHR. In contrast, the lack of melanin, paucity
of melanin, or presence of eumelanin in the hair follicle, which clinically
correlates to white or gray, is predictive of a poor response to LHR.
3. Investigations: Ideally all females with hirsutism in the reproductive age
group should be investigated between 2 and 5 day of cycle. Free testosterone
is usually the best marker. 17 alpha OH progesterone test done during the
luteal phase, is good for investigating females with normal cycles. LH:FSH
ratio of 1.6 or more has been proposed to be a marker for evolving PCOS,
especially in young females. Altered ratio is also a marker for end organ
hypersensitivity. Ultrasongraphic string of pearl appearance is considered a
useful investigation.
4. General Advice to Patients: The patients are advised not to carry out parlor
activity like waxing, threading, plucking or bleach 3 weeks before the first
session and in between the sessions. Use of hair removing creams should be
discouraged due to the chances of irritant reaction. The patients are allowed
to shave in between the sessions. The patients can use bleach with 1 month
gap before and after the session, when the gap between sessions is more than
3 months and during the maintenance phase.
5. Pre- and post-procedure photographs: Keeping a photographic pre-,
post- procedure and in-between sessions in comparable setting is important.
It helps the patient as well as the treating physician to compare the response/
nonresponse. Trichoscan images can prove to be extremely useful for
monitoring the results.
Patients records should be maintained including the exact area treated,
skin and hair type, the fluence used and wavelengths used during all sessions
and treatment response.
Intraoperative
Intraoperative anesthesia: Topical anesthetic creams are available. They are
used especially for sensitive areas, e.g. pubic region. However, the authors
do not prefer the use of topical anesthetic preparations as they have a high
potential of causing irritant reactions and subsequently burns with laser. They
also increase the cost of a given session and the time required to complete a
session. Also cooling is a very effective alternative.
The need for topical anesthesia is variable among patients and anatomic
sites. Various topical anesthetics including lidocaine, lidocaine/prilocaine,
and other amide/ester anesthetic combinations can be used to diminish the
procedural discomfort, and should be applied 30 minutes to 1 hour before
treatment under occlusion. Care should be taken when using lidocaine or
prilocaine to apply these medications to a limited area to diminish the risk of
lidocaine toxicity or methemoglobnemia, respectively. Deaths have resulted
from lidocaine toxicity resulting from occlusion of the back as well as lower
extremities with topical lidocaine. Likewise, systemic toxicity can occur with
the use of any topical anesthetic in large amounts.
Test patch: A small test patch area should ideally be done before the first
session to determine the optimum fluences and skin reaction to the laser. It
is especially useful in dark skin types to establish the optimum fluences that
can be used in these patients without causing any burns.
Procedure: Procedure is re-explained to the patient in brief. The skin is
checked for any sensitive areas, tanning or any cuts under adequate light with
a magnifying glass. Depending on the area to be treated, the patient can be in
a supine or sitting position chairs or adjustable operation tables.
1. Marking: The area to be lased is marked with a white pencil under
adequate light. Red pencil can be used with IPL. Small grids should be
made for large areas.
2. Shaving: Cleansing gel is applied and the area is shaved taking care
not to leave any hair behind and at the same time avoid any cuts on the
skin due to vigorous shaving. Magnifying glass should be used to ensure
proper shaving. Shaving against the direction of hair should be avoided
(Fig. 6.3).
3. Cooling: Pre-cooling, post-cooling and cooling during the session is
absolutely mandatory. Chill tip is very effective for this. Ice packs can be
used for large body parts.
4. Gel application: Cool gel in a thin layer needs to be applied in all lasers
except the big hand piece of light sheer duet.
5. Eye protection: Patient and operator should wear glasses.
The parameters are decided on the basis of hair and skin type. The hand
piece of the system should be placed perpendicularly to the skin surface
and it should be pressed gently to displace blood from capillaries and
to bring the hair follicle nearer to the aiming source (this is particularly
important if you are using Nd:YAG laser). Overlapping of handpieces in
treating adjacent areas (10%) is ideal as it avoids skipping of areas.
Laser shots are given at the optimum fluence according to the skin and
hair type and the response of patient to patch test or previous sessions.
Postoperative
1. Post-procedure care: There can be mild-transient erythema and
perifollicular edema. A steroid antibiotic cream can be used. Oral
antiallergic or rarely oral steroids might be needed in case of a burn.
All the patients are advised regular use of sunscreen and use of a
moisturizing cream for 5 days after any laser session.
2. Patient follow-up: The best time to evaluate the effect of laser session is
23 weeks post the session (Figs 6.4 and 6.5).
Non-responsive Lesson: The patients with fine (Fig. 6.6), gray (Fig. 6.7)/
blonde/light brown hair have inadequate pigment in hair hence do not
respond well.
Fig. 6.3: Shaving against the grain leading to erythema and bleeding points
Figs 6.4A and B: (A) A patient treated with long-pulsed Nd:YAG laser; (B) Treatment
response after 6 sessions of long-pulsed Nd:YAG laser
Figs 6.5A and B: Treatment response after six sessions of long-pulsed Nd:YAG laser.
(A) Preoperative; (B) Postoperative
Fig. 6.6: A patient with a few gray hair it must be emphasised that the nonpigmented hair are unresponsive
Fig. 6.7: A patients with multiple gray hair, which is not a candidate for LHR
If very low fluences are used, patients do not get the desired response.
Low energy machine which is not delivering the right energy is another factor
for non-response. Underlying hormonal disturbances is also a reason for
suboptimal response.
Side Effects
In majority of cases, the side effects are transient and easily remediable. Sun
protected regions are less likely to suffer from side effects as compared to
photo-exposed areas, e.g. face and arms. The most common skin reactions
are pain during session, mild burning, transient erythema post-session,
perifollicular erythema. In very few cases persistent erythema, vesiculation,
crusting, hyperpigmentation, hypopigmentation and permanent scarring
can occur.
Thermal burns can occur which can be superficial or deep. This may
result either from selecting a non-optimal wavelength, pulse duration,
fluence, nonfunctional epidermal cooling, or by treating a tanned patient.
Superficial burns (Fig. 6.8) are more prone to occur in patients with tan,
dry skin or rigorous shaving. They need couseling, mild topical steroids and
moisturizers.
If a patient has extreme burning sensation, there is high probability that a
deep burn (Fig. 6.9) has occurred.
For this, the patient should start oral steroids (dose of 1 mg/kg body
weight) for three days. After three days, advice the patient to use a steroid
antibiotic combination and bland moisturisers. Hyperpigmentation can be
treated with mild agents like topical vitamin C and strict sun protection.
Paradoxical hair stimulation (Fig. 6.10) can occur as a side effect. Few
patients have increased hair growth at sites surrounding previously treated
sites or increase in hair growth over the treated site. This effect tends to
occur more frequently in patients of skin types III or higher, more commonly
with IPL and in an adjacent area of untreated skin. This effect has also been
reported in individuals with previously undiagnosed hormonal conditions,
such as polycystic ovarian syndrome, emphasizing the importance of history
taking and proper patient selection in laser hair removal. The paradoxical
hair stimulation occurs probably due to lower-range fluence. Use of higher
fluences reduces this side effect.
Fig. 6.8: Superficial laser burns, consequent to inadequate cooling
Fig. 6.9: Deep laser burns in a patient of laser hair removal
Fig. 6.10: Paradoxical hair stimulation seen in a pigmented skin patient
Increasing the area to be lased in the maintenance sessions is another

very common cause of paradoxical hair stimulation.
Inadequate cooling can also lead to paradoxical hair stimulation.
Especially when working with IPL, the surrounding area should also be
cooled as unlike lasers, IPL is not a coherent beam and heat can lead to
increased hair growth.
Ocular injury is another potential complication of laser hair removal.
Pearls and Pitfalls

1. Spacing between sessions: FaceThe authors recommend that the
firsttwo sessions can be done at an interval of 4 weeks to target the hair
in the early anagen phase, after that the gap can be increased. The resting
phase of facial hair is around 4 weeks. One of the most prominent effects
of laser is the prolongation of the resting phase. Hence we recommend
that the sessions should be spaced out from the 3rd session itself to
target the hair in the anagen phase. Preforming the sessions frequently
might lead to a temporary suppression rather than destruction of hair
follicle.
If large body parts are to be treated the authors recommend that the gap
between first and sessions should be 68 weeks and gradually the gap
can be further increased in subsequent sessions.
2. Maintenance sessions: These are regular laser sessions done at
frequency of 13 times per year. The frequency depends on the area
treated and the response of laser sessions.
3. Long hair (Fig. 6.11): This process is known to happen with all kinds of
hair reduction technologies. The lased hair is pushed into a prolonged
anagen phase. The patient should be informed about this in the
beginning and proactively advised to use scissors to cut these long hair
in the maintenance phase.
Fig. 6.11: Persisting long haira process known to occur with all kinds of hair
reduction technologies
Safety Issues
Standard Precautionary Measures
1. Eye protection: The recommended eye protection devices should be
used at all times by any person present in the laser room.
Clinicians eyewear: Appropriate protective eyeglasses according to the
wavelength of laser being used has to be worn by the clinician.
Patients eyewear: Opaque or metal goggles, corneal shields, or
protective wet eye pads should be used by the patient during the
procedure.
The clinician/patient should never look directly into laser aperture,
even when wearing laser safety glasses. Avoid directing laser beam
anywhere other than within holster or at intended treatment area.
Remove mirror-like surfaces from vicinity of laser beam path. Do not
treat eyebrows, eyelashes, or other areas within bony area surrounding
orbit. This topic is extensively discussed in the appendix of the book.
2. Fire protection: Flammable or explosives should not be used in the
laser room. Acetone or alcohol-based skin preparations should not be
used. Fire-retardant drapes and gowns should be used. Fire extinguisher
and water should be readily available in the clinic.
3. Electrical safety: Many lasers use high voltage and high current electrical
power, ensure proper grounding. Proper cables should be used instead
of extension cords. Good wiring and proper stabilizers should be used.
Special Situations
1. Role of eflornithine along with laser hair reduction: The role of topical
eflornithine is still controversial. It is being used by some practitioners
in the maintenance phase to delay hair growth. Twice a day application

is suggested and the results are usually seen after 46 weeks. This can
lead to acne in patients with acne prone skin and it also significantly
increases the cost of therapy for the patient.
2. Polyscytic ovarian disorders (pcod) and laser hair reduction:
In case of clinical signs suggestive of PCOD (like abnormal cycles, acne over
lower face, obesity and thinning of frontal hair), a hormonal profile should
be carried out between the 2nd and 5th day of the cycle and an ultrasound
of the lower abdomen is advised. In cases where PCOD is documented,
an endocrinological opinion should be sought. The patients are started
on medical therapy followed by laser treatment from the second month
onwards ideally. Many practitioners start medical and laser therapy
simultaneously. These patients should be counseled regarding the
requirement of increased number of sessions.
3. Laser for gray hair: Melanin is the chromophore targeted by laser. Gray
hair lack melanin, hence the treatment is unsuccessful. The patient
should be informed in advance that these hair will not respond to laser
and as the number of black hair decreases, the patient would feel that
number of gray hair has increased. Few gray hair can be managed by
electrolysis. If the percentage of gray hair is more than 50%, laser should
be avoided.
Removal of non-pigmented hairs with a combined light/bipolar
radio-frequency device with or without pre-treatment with a topical
photosensitizer has shown little success. Integrated radiofrequency
and optical energy technology might represent a new photoepilatory
technique for the long-term removal of white hair. Although results may
not be quite as efficient as with chromophore targeting primarily lightbased technologies.
A recent alternative approach to treat white, blond and gray hair with
laser hair removal has been the external application of melanin to the
hair through the use of liposome technology. Melanin-encapsulated
liposomes have demonstrated to selectively deliver melanin to the
follicle and hair shaft. The effectiveness of these modalities for gray hair
still needs to be proved.
4. Lasers for fine hair: In Indian skin due to the high melanin content
and the risk of burns, very high energies cannot be used with any laser
systems. For patients, who are left with fine hair after receiving a number
of laser sessions, the pulse width needs to be decreased and high fluence
levels are needed. Hence, patients with fine hair should be dissuaded for
laser hair reduction.
5. Pseudofolliculitis: Laser hair reduction is a very effective treatment for
pseudofollicultis seen post waxing in females and post shaving in males.
The laser should be done at low energy levels and usually 34 sessions
are sufficient to make the hair fine and hence solve the problem of
pseudofolliculitis (Figs 6.12 and 6.13).
Fig. 6.12: Patient with pseudofolliculitis barbae treated with hair reduction lasers
Fig. 6.13: Same patient after two months after first session with Nd:YAG laser
6. Lasers in dark skin types: There are several characteristics which make
skin of dark color more susceptible to laser-related complications.
There are several factors which can be taken into account to minimize
the complications:
Wavelength: Use longer wavelengths as they are associated with less
epidermal absorption and hence greater safety.
Treatment parameters: Use lower (optimum) fluences and longer pulse
durations for laser hair removal. These can be determined by doing a
patch test.
Pre- and post-treatment advice: Sun protection is an important aspect
to prevent any complications, e.g.postinflammatory hyperpigmentation.
Epidermal cooling: Adequate cooling is one of the key factors in
determining the safety.
Topical corticosteroids: Consider using in patients with post-treatment

erythema or edema to reduce chances of post inflammatory hyperpi
gmentation.
7. Laser in pregnant women: Treatment of a pregnant woman for nonurgent conditions is discouraged, although there is no evidence
suggesting a potential risk to pregnant women undergoing LHR.
Future Advances
1. Pain free lasers: A novel technique to reduce LHR-associated pain
is pneumatic skin flattening (PSF). PSF works by coupling a vacuum
chamber to generate negative pressure and to flatten the skin against
the hand piece treatment window. Based on the gate theory of pain
transmission, it stimulates pressure receptors in the skin immediately
prior to firing of the laser pulse, thereby blocking activation of pain
fibers. Light sheer duet has pneumatic skin flattening in which vacuum
is used for decreasing the pain.

Alma Lasers unique IN-MotionTM technology combines concurrent
cooling with a gradual thermal rise to the targets therapeutic
temperature, without the risk of injury and with much less pain for the
patient. This is in contrast to the high peak energies used in traditional
photoepilation technology that requires high cooling before, during and
after each pulse, and requires that the handpiece remains stationary
during the energy delivery. The sweeping technique of IN-MotionTM
technology enables continuous administration in a larger treatment
area for increased comfort and fewer missed spots.
2. Meladine, a topical melanin chromophore, has been studied in Europe
with interesting results. The liposome solution dye, which is sprayed on,
is selectively absorbed by the hair follicle and not the skin. This gives
the follicles a temporary boost of melanin to optimize laser hair removal
treatments. Clinical studies in Europe have shown vast permanent hair
reduction in patients who used meladine prior to treatment.
3. Studies have shown that eornithine in combination with the
alexandrite or Nd:YAG laser (Fig. 6.13), may increase the efcacy of laser
hair removal and that topical melanin improves the efcacy of the diode
laser.
4. Photodynamic therapy (PDT) with aminolevulinic acid (ALA) has been
shown in a small pilot study to result in up to 40% hair reduction with a
single treatment, although wax epilation was performed prior to treatment
in this study.
5. Electro-optical synergy (ELOS) technology combines electrical
(conducted radiofrequency) and optical (laser/light) energies. A
handful of devices based on this technology have been produced. The
theory behind ELOS is based on the optical component (laser or IPL)
heating the hair shaft, which then is thought to concentrate the bipolar
radiofrequency (RF) energy to the surrounding hair follicle. Based on
this combination, lower fluences are needed for the optical component,
thereby suggesting it might be well tolerated in all Fitzpatrick skin
phototypes, and potentially effective in the removal of white and poorly
pigmented hair. A study of 40 patients (Fitzpatrick skin phenotypes IIV)
with varied facial and non-facial hair colors were treated with combined
IPL/RF ELOS technology. An average clearance of 75% was observed at
18 months following four treatments. No significant adverse sequelae
were noted and there were no treatment differences between patients
of varying skin types or hair color. Pre-treatment with aminolevulinic
acid (ALA) prior to use of a combined IPL and radiofrequency device
has been shown to further augment the removal of terminal white hair.
As hair removal lasers are possibly the most common indication in the
laser industry, more advances are bound to take place to tackle some of the
special situations detailed in the chapter.
Bibliography
1. Buddhadev RM. Standard guidelines of care: Laser and IPL hair reduction.
Indian J Dermatol VenereolLeprol. 2008;74:S68-S74.
2. Faurschou A, Haedersdal M. Photoepilation of Unwanted Hair Growth. Raulin C,
Karsai S (Eds). Laser and IPL Technology in Dermatology and Aesthetic Medicine,
DOI: 10.1007/978-3-642-03438-1_9, Springer-Verlag Berlin Heidelberg, 2011.
3. Murphy MJ, Torstensson PA. Thermal relaxation times: an outdated concept in
photothermal treatments. Lasers Med Sci. 2013.
4. Nanda S, Bansal S. Safety and efficacy of Nd YAG Laser in type IV and V skin: a
study on 200 patients. Indian J Dermatol.
5. Tierney EP, Goldberg DJ. Laser hair removalpearls. JCosmet Laser Ther. 2008;
10:17-23.
Section
Advanced
Laser Interventions
Chapter
Nonablative and Subsurface

Rejuvenation
Kabir Sardana
Introduction
The demand for newer methods of skin resurfacing (for acne scarring,
pigmentation, and improvement of skin texture and pore size) has made
the use of nonablative lasers and light devices popular in clinical practice.
These treatment modalities work on deeper skin layers without removing the
epidermis, resulting in collagen synthesis and remodeling without protracted
healing. Consequently, nonablative technology has several benefits. Most
importantly, it is a safe and effective treatment in all skin types and colors
with a minimal amount of required recovery time.
A clear definition of nonablative skin rejuvenation is important as the term
is sometimes used haphazardly. There are some terms that have different
connotations.
1. Nonablative rejuvenation: This is defined as improvement of skin
quality without physical removal or vaporization of the skin.
2. Nonablative fractional rejuvenation (NAFR): This implies the use of
fractional lasers, which work by removing a fraction of the skin with
an intact epidermis, thus leading to mimimum down time and rapid
healing.
3. Subsurface lasers: These are lasers and light sources that work by
altering the tissue below epidermis and is akin to the term nonablative
laser resurfacing or laser toning.
4. Minimally ablative lasers: This term includes procedures where a
proportion of the epidermis is also targeted and includes lasers like the
KTP lasers, light devices like IPL and fractional ablative lasers and LED.
In practice as photodamage has a marked epidermal component, these
devices are more useful than pure subsurface lasers for the indication.
As discussed below in an endeavor to bridge the gap between less side
effects and results the tide has turned and ablative fractional lasers (AFR) are
also being increasingly used, which are strictly not nonablative lasers.
Mode of Action
Most of these devices work by targeting the dermis. They work either by,
targeting discrete chromophores in the dermis and/or at the dermal epidermal
junction. They primarily use mid-infrared lasers in the range of 1.31.55 m
wavelengths, where water absorption is weak enough so that relatively deep
beam penetration is allowed (there is only 50% beam attenuation at depths
of 3001,500m).
The classification system of Richard Glogau (Table 7.1), is useful to assess
clinical photoaging. The importance of this is that patient of Grade I are easy
to treat while Grade II and III require a combination of approaches. One can
follow a patient from an early age, with relatively strong homogeneity of skin
coloration and minimal wrinkles, to a more aged patient, with wrinkles at rest
and a more heterogeneous skin coloration.
Treatment of photodamage can be divided into various categories, and
treatment protocols are based on a logical approach founded on the lasertissue interactions delineated above. The goal should be to maximize skin
rejuvenation, from reducing telangiectasias and lentigines to enhancing
dermal remodeling.
Classification of Lasers
The main classifications of lasers and light sources utilized for
photorejuvenation are outlined in Box 7.1. Though we admit that this such
classifications is arbitrary as many devices are capable of delivering multiple
wavelengths.
Table 7.1 Classification of photodamage skin
Grade
Classification
Age
Wrinkles
Clinical findings
Cosmetic
camouflage
Mild
20s or
30s
No wrinkles
Early photoaging:
Mild pigmentary change
No keratoses
Minimal wrinkles
Minimal or no
makeup
II
Moderate
30s or
40s
Wrinkles in
motion
Early to moderate
photoaging: Early solar
lentigines, keratoses
palpable but not visible
Parallel smile lines begin
to appear
Wears some
foundation
III
Advanced
50s
Wrinkles at
rest
Advanced photoaging:
Dyschromia
Visible telangiectasias
Visible keratoses
Always
wears heavy
foundation
IV
Severe
60s and
older
Only
wrinkles
Severe photoaging:
Yellow-gray skin color
Wrinkles throughout
Makeup cakes
and cracks
Nonablative and Subsurface Rejuvenation 277

Box 7.1 Lasers and light sources used for photorejuvenation*
Class
Laser/Device
Energy
Visible light/
Vascularselective
laser
KTP lasers (532 nm)

Diode pumped
Up to 950 J/cm
5100 ms
0.15 W
51000 ms
Visible nonlaser
light sources
Pulse duration
2
0.4540 ms
PDL (585/595)
Up to 40 J/cm2
Intense pulsed light

(IPL) (5001,200 nm)
Up to 70 mJ/cm
1500 ms
Qswitched and
millisecond domain
Nd:YAG 1064 nm
Up to 16 J/cm2
Up to 990 J/cm2
520 ms
0.1300 ms
1,319 nm Nd:YAG laser
Upto 30 J/cm2
5200 ms
1,320 nm Nd:YAG laser
540 J/cm2
30200 ms
1,450 nm diode laser
Up to 25 J/cm
201250 ms
12 W
51000 ms
1,540 nm erbium glass

laser
1030 J/cm
LED (lightemitting
diodes)
Infrared lasers
(target pigment,
hemoglobin and
water)
PlasmaRF
3100 ms
0.54 J
*Radiofrequency (RF), microwave and ultrasound
1. The first category is visible light lasers or light sources that have more
absorption by hemoglobin and melanin. These visible light sources
and lasers have more influence on the telangiectatic and melanocytic
components of photoaging. These sources can be subdivided into co
herent, single wavelength, broadband (flashlamps) or narrowband such
as light-emitting diodes (LED). Intense pulsed light is a broadband light
source with filters used to limit the lower end of the emitted spectrum.
2. The next category is infrared lasers with absorption predominantly by
water. Infrared wavelengths with primarily water absorption are used
to create thermal dermal and collagen injury. The most commonly
employed devices are 1,320 nm, 1,450 nm and 1,540 nm lasers,
although narrowband infrared LED devices, other filtered light sources
and possibly ultrasound may be available in the future.
3. Another category is the near infrared lasers or light sources, which are
absorbed by a combination of melanin, hemoglobin and water. The
tradeoff is that these wavelengths are absorbed at a lesser intensity but
cover more targets. The flashlamp pumped 1,064 nm Nd:YAG laser is the
most commonly used example. The broadband flashlamp pumped light
sources also have a number of effects for structural photorejuvenation
in that they emit not only wavelengths absorbed by melanin and
hemoglobin, but wavelengths absorbed by water as well. IPL broadband
sources emit 515 nm to 1,200 nm.
4. Other devices on the market use RF to heat tissue. Depending on the

delivery system and frequency, deep or superficial heating can be
produced. Monopolar RF has a very different and deeper penetration
(as the result of the patient being grounded) than bipolar RF devices, in
which the RF travels from one electrode to another over relatively short
distances. Microwave devices have been used to heat specific targets
such as blood vessels or hair but none have been commercialized.
Use of nondiagnostic ultrasound frequencies may also be used in skin
tightening.
5. Fractional resurfacing is a method of microablative, pixel like damage of
the skin with rapid healing resulting in skin contraction, dermal collagen
thickening and improvement in rhytides.
The vascular lasers are operated at subpurpuric uences and pulse
durations with minimal overlap during passes (Box 7.1). Approximately ve
treatments are administered every 34 weeks.
The IPL devices vary among systems, but all require cold aqueous gel
application prior to treatment. A series of 56 sessions is usually necessary
with multiple passes during each session.
Infrared lasers are operated at the highest tolerated energy level to ensure
the best results. A cryogen spray is delivered milliseconds before laser pulsing
in order to protect the epidermis from thermal injury. Treatments generally
occur in a series of 56 sessions at 24 week intervals. Depending on the laser
used, 13 passes with the laser can be made per treatment (Box 7.1).
Unlike the nonablative lasers, light-based treatments like the LEDs do
not cause gross thermal heating, but instead cause subtle molecular changes
in the tissue for clinical improvement. For example, yellow (590 nm) LED
irradiation is known to downregulate metalloprotease-1 (collagenase) and
stimulate broblasts to increase procollagen production, while continuous
red (633 nm) LED irradiation stimulates mast cell degranulation and
increases broblast growth factor production. The pulsed yellow LED,
when used twice a week for 4 weeks, was shown in two prospective blinded
studies (with 183 patients) to mildly improve skin texture, dyspigmentation,
erythema, and ne lines in the periorbital region in the majority of patients
as assessed by blinded observers, patient reports, digital microscopy, and
ultrasound. The recommended treatment course consists of less than
1 minute irradiations twice a week for 4 weeks, followed by a monthly booster
treatment. Exfoliation with an enzymatic peel or microdermabrasion prior to
treatment is also recommended.
In order to bridge the gap between nonablative and ablative devices,
fractional resurfacing technique was developed. Similar to nonablative lasers,
the fractional laser (1,550 nm erbium-doped and 1,540 nm erbium:glass)
emits infrared light that is absorbed by water-containing tissue. Further,
technological developments have resulted in the use of the radiofrequency
and light devices for skin rejuvenation, particularly for the treatment of skin
laxity by heating deeper skin and subcutaneous tissue, causing skin and
tissue tightening. These devices have been discussed previously.
A new RF tool, the Portrait plasma skin regeneration (PSR 3) device,
has been shown to improve skin texture, tone, ne lines, dyschromia, and
rhytides. The plasma is emitted in millisecond pulses to deliver energy to the
desired tissue without reliance on a skin chromophore, and energy settings
on the device can be varied for different depths. One disadvantage of this
technology is that there is about a 1-week period of required downtime.
Vascular Lasers
Studies have shown that KTP lasers have better collagen formation
results when compared to 1,064 nm lasers in the treatment of skin photorejuvenation.
Pulsed dye lasers (PDL) function best in the treatment of vascular lesions
(i.e. port wine stains and hemangiomas) with significant production of
procollagen type I and type III. Increased activity of dermal fibroblasts and
mucin, as well as the thickening of the stratum spinosum in the dermis, has
been noticed in the restoration of degenerated skin. The use of modern PDL
systems for skin rejuvenation provides nonablative results by minimizing
sideeffects and reducing purpura.
Study Results
Zelickson and Kilmer determined that purpurogenic doses of the PDL also
induced broblast proliferation and the production of the Grenz zone of
new collagen in the papillary dermis, benecial for resurfacing. Though
early studies, showed a good histological response, there was little patient
satisfaction.
In 2004, Trelles et al. compared the effects of the 595 nm PDL to a
1,450 nm diode laser and to a combination treatment with both lasers. The
combination protocol was found to be better. It has been proposed that the
logic of combination is that following the removal of the vascular-associated
pigment from the supercial dermis by the PDL, enables deeper penetration
of the following pulse with the 1,450 nm diode, helping to amplify the woundhealing response. This has led to a combination approach of PDL with other
laser systems (595/1,064 nm).
Many other wavelengths that target hemoglobin in blood vessels have
been used, which include the long-pulsed 755 nm alexandrite laser, 810 nm
diode, and the 1,064 Nd:YAG lasers. The 1,064 nm Nd:YAG laser induces
deeperremodeling than the 532 nm laser due to its lower degree of dermal
scattering and chromophore absorption at 1,064 nm. Thus, the logic of
combining 532 nm laser to treat dyschromia and telangiectasia and following
it with the 1,064 nm laser to obtain some deeper remodeling in the same
treatment session.
Intense Pulsed Light

Intense pulsed light (IPL) devices emit polychromatic light in broad ranges
of wavelengths, selectively filtered to target specific chromophores, between
500 and 1,200 nm. IPLs treat vascular lesions, pigmentation, and have shown
to have an effect in the production of collagen and elastic fibers in the dermis.
Studies have shown that IPL photorejuvenation treatments using cooling
apparatuses considerably increase epidermal thickness, and improve skin
texture. This necessitates a proper cooling to avoid the adverse effects relating
to skin damaged.
The addition of radiofrequency has been utilized to supplement and
improve outcomes with use of IPL devices (Elos, Syneron). Bipolar radio
frequency exhibits a preference for warmer tissue. This technology considers
this property by utilizing the IPL system to heat the target chromophore and
then using the radiofrequency technology to target the now warmer tissue
target.
Study Results
Bitter et al. studied the effect of a series of treatments with the IPL
(photorejuvenation) in 49 patients. After 46 IPL sessions every 3 weeks, more
than 90% of patients had improvement in all aspects of photoaging: 50% or
greater improvement was noted by 46% of patients for ne wrinkles, 72% for
skin smoothness, 70% for telangiectasias, 67% for decreased pore size, 59%
for facial erythema, and 50% for ushing.
In a multicenter study of 93 patients (skin phototypes IIII, Fitzpatrick
Wrinkle Classes III, and Elastosis Scores 16), Sadick et al. gave 5 treatments
at monthly intervals with the 560 or 640 nm cutoff lter. The markedly
favorable results at 4- and 6-month follow-up visits confirmed its long lasting
results.
Further studies (Negishi et al.) have used a longer pulse durations with a
cutoff lter at 590 nm, to treat photoaging in skin type IV. Long-term followup results have confirmed sustained improvement of the face, neck, and
chest up to 4 years after treatment.
Summary
Even though newer systems have improved user friendly pre-programmed
settings, one should become comfortable with one or two IPL systems as
each has different interfaces, wavelength spectrums, filters, power outputs,
pulse profiles, cooling systems, and spot sizes. In fact, the variations make it
impossible to compare the different IPL devices. This is as some IPL devices
that calculate fluences based partly on theoretical modeling and photon
recycling whereas others determine fluence based solely on an actual output

at the sapphire or quartz window on the handpiece tip.
Our own experience with this modality in Indian skin has been less
enthusiastic and we feel that the fluencies recommended can cause side
effects and a lower dose can have little objective benefit.
Light-emitting Diodes
Light-emitting diodes (LED) provide athermal and atraumatic photo
activation of mitochondria, epidermis and fibroblasts. The singular advantage
of LED devices is that they are well tolerated by patients. Typically, LED devices
emit a range of wavelengths. The interaction of LED devices with the skin is
unclear, though photomodulation of cell receptors, cell organelles, or existing
protein products is the possible mechanisom. Unlike many of the devices
discussed above, non-thermal interactions with the extracellular matrix
and fibroblasts remodel existing collagen, increase collagen production by
fibroblasts, inhibit collagenase activity, and result in rhytid reduction.
Combination of various LED wavelengths is the key to clinical efficacy.
One wavelength will not target all chromophores optimally. Based on
the published peer-reviewed literature, a combination of wavelengths is
necessary for effective LED phototherapies are given in Table 7.2.
The wavelengths used for LED skin rejuvenation have been near IR at 830
nm applied first, followed by 633 nm 72 hours later, repeated over 4 weeks.
The reasons for these wavelengths and the order in which they are applied
are photobiologically based on the precepts of the wound healing cycle. Both
of these wavelengths involve the basal keratinocytes and also target dermal
cells, with beneficial effects to both the cellularity and organization of the
epidermis (Table 7.2).
Study Results
Lee and colleagues, in the first controlled study in the peer-reviewed literature,
compared LED skin rejuvenation in a total of 76 patients randomly assigned
to four groups: 830 nm LED therapy on its own, 633 nm LED therapy on its
own, the combination therapy with 830 nm and 633 nm and a sham irradiated
group. All patients were treated hemifacially, so there were intrapatient
Table 7.2
A summary of the LED wavelengths and clinical utility
Wavelength
Indications
633 nm + ALA PDT
Non-melanoma skin cancers
Blue 415 nm endogenous PDT + red 633 nm
Acne vulgaris
Near infrared 833 nm + 633 nm
Skin rejuvenation, wound healing
595 nm yellow light
Rosacea, skin rejuvenation
as well as intergroup controls. In addition, to clinical photography and

subjective patient assessment, Dr Lee tested the results with profilometry and
instrumental measurement of skin melanin and elasticity. She also carried
out histological, immunohistochemical and biochemical assays. She found
that wrinkles and skin elasticity were best improved in the 830 nm-treated
groups, skin lightening was best in the 633 nm group, so the combination of
the two wavelengths was able to achieve the best overall efficacy and high
patient satisfaction with the results, with statistical significance seen between
all treated groups and the sham-irradiated controls, and a statistically
significant improvement between the treated and occluded sides in all of
the experimental groups, but not in the sham irradiated group. The clinical
photography was backed up by the histological findings for both collagenesis
and elastinogenesis, which was proved to take place in all dermal layers down
to the deep reticular dermis.
A 90-subject prospective study by Weiss et al. (2005) using a 590 nm
nonthermal full-face LED (eight treatments over 4 weeks with a minimum
of 48 hours between treatments) showed a global improvement of more than
85% and a self-assessment improvement of 84% in patients at 4 months. With
digital imaging, there was a 90% reduction in the signs of photoaging: Smoother
texture, and reduced periorbital wrinkles, erythema, and pigmentation.
However, prolometry results only showed a 10% improvement by surface
measurements.

In a prospective study using the OmniluxTM LED system, a combination
of IR (633 nm) and near-IR (830 nm) light with uences of 126 and 66 J/
cm2, respectively, 31 patients underwent 9 treatments: 830 nm light on days
1, 3, 5, 15, 22, and 29, and 633 nm light on days 8, 10, and 12 (Russel BA).
Patient satisfaction scores, photos, and prolometry were used to assess
improvement at 9 and 12 weeks. A clinically signicant reduction in surface
roughness, maximum prole peak height, and maximum height of the
prole was demonstrated. Fifty-two percent of the subjects had a 2550%
improvement in photoaging scores at 12 weeks, and 81% displayed a signi
cant improvement in periorbital rhytides at the end of the study.
The Gentle Waves device (Light BioScience, LLC, Virginia Beach, VA),
which generates a 588 nm yellow light pulses with an on-time of 250 ms
and off-times of 10 ms for a total of 100 pulses resulting in a total light dose
of 0.1 J/cm2. Boulos found that there was a strong placebo effect with the
588 nm Gentle Waves system, and that little objective improvement was
observed by blinded raters. Despite the subjective improvement in two trials,
objective improvement in blinded studies is unproven. But as stated above a
combination approach is better than the use of a single wavelength.
Consequently, LED combination therapy is a safe and effective method
of skin resurfacing, but in order to optimize treatment parameters, further
studies are necessary.
Infrared Laser
The 1,320 nm Nd:YAG laser was the first commonly used nonablative midinfrared laser to rejuvenate skin.
The Q-switched 1,064 nm laser systems that stimulate deep dermal
collagen stimulation had revealed faster healing than carbon dioxide
systems. Further, studies have shown that Q-switched 1,064 nm laser devices
significantly decrease solar elastosis and thicken upper papillary dermal
zones of collagen. The 1,064 nm Nd: YAG laser devices have useful skin
lightening mechanisms for skin rejuvenation.
With the use of epidermal cooling devices, such as cryogen, 1,319/1,320
nm laser devices have provided optimal results in the formation of new
collagen, reduction of lines and wrinkles. These nonablative laser systems
leave the epidermis intact and provide great results in all skin rejuvenating
procedures.
The 1,450 nm mid-infrared diode laser systems have functioned
successfully in the treatment of active inflammatory acne vulgaris, acne
scars on the face, fine lines and wrinkles. This laser system targets dermal
water, creates a wound in the dermis and triggers the regeneration process of
collagen.
The 1,540 nm Erbium:Glass laser devices have also clinically shown to
help in dermal remodeling by treating fine lines and wrinkles, acne vulgaris
and acne scars, and atrophic scars on the face. These lasers use a sapphire
lens cooling device throughout the treatment process.
One issue with these devices is the side effects that range from dyschromia,
purpura, and blistering to scarring. Epidermal cooling techniques are
imperative in patients with Fitzpatrick IVVI type skin. The 1,320 nm Nd:YAG
uses either a pre- or post-laser spray, while the 1,450 nm diode laser applies
cryogen before, during, and after the laser pulse. These are ideal for Fitzpatrick
IV, V, and VI skin types. As in the case of the 1,450 nm system, the total spray
time is delivered over a long period (up to 220 ms), there is a risk of cryoinjury.
Thus, the shorter spray times with the 1320 nm laser and the 5C sapphire lens
incorporated into the 1,540 nm erbium:glass laser are a better option.
Study Results
Infrared laser-1,064 nm Nd:YAG: The LP Nd:YAG laser, like the PDL, is a
vasculature-selective device and works best for red pigment and vascular
lesions. This has also been used for treatment of photodamaged skin,
improving dyspigmentation, skin tone, and texture. Studies by Goldberg DJ,
1997 and Cisneros JL,1998 have shown that the QS laser can be considered as
a modestly effective treatment for wrinkles, lentigines, and acne scarring. In
2006, a short-pulsed 1,064 nm Nd:YAG laser was developed for more effective
acne scar reduction. This pilot study in 9 patients with moderate-to-severe
facial acne scars used this laser with a low uence (14 J/cm2) and after eight
sequential treatments (Lipper GM) there was marked improvement in acne
scarring.
Infrared laser-1,320 nm Nd:YAG: The CoolTouch laser (CoolTouch,
Roseville, CA) was the rst device specically designed for nonablative
resurfacing and improving skin texture. It has been tried both in acne and
photodamaged skin. Chan et al. studied this lasers effect on wrinkle reduction
and the treatment of acne scarring in 27 Asian females. The protocol was a
monthly treatment for 6 months with 3 passes per session and objectively
only a mild improvement or no change was seen in most cases.
In 2006, Bhatia et al. performed a study utilizing structured interviews of
34 patients 3 months after undergoing a series of 6 monthly treatments with
the CoolTouch laser for the treatment of acne scarring or photodamage. This
study noticed that patient satisfaction was high and textural improvement
were seen.
These studies suggest that although the 1,320 nm Nd:YAG shows a mildto-moderate benet for wrinkling and acne scarring, but patients are more
than satised with the results than the clinician.
Infrared 1,450 nm diode: Similar to the CoolTouch laser, the 1,450 nm
diode (SmoothBeam, Candela, Wayland, MA) uses a cryogen cooling device
to protect the epidermis during treatment and delivers energy via a 4- or
6-mm spot. In addition to its thermal effects on the dermis, it also damages
sebaceous glands, thereby making it a useful treatment option for acne.
Mild-to-moderate improvement was seen in 12 of the 16 patients on the
treated side in a split face study (Ross EV, 2000). Another study in patients
with mild-to-moderate perioral or periorbital wrinkles, Tanzi et al. (2003)
demonstrated mild-to-moderate improvement of wrinkles. An increase in
dermal collagen was seen at 6 months after the last treatment, and patient
satisfaction scores reected the histological and photographic changes.
Tanzi and Alster later compared this laser to the 1,320 nm Nd:YAG for the
treatment of atrophic facial scars in 20 patients receiving three successive
treatments with a LP 1,320 nm Nd:YAG laser on one side of the face and with
a LP 1,450 nm diode laser on the other side. Both lasers improved atrophic
scarring but the 1,450 nm diode laser showed a greater clinical scar response.
Some authors have suggested that if 3 passes with the 1,320 nm Nd:YAG
had been performed improved results can be achieved. As a result, using the
3 pass protocol with the Nd:YAG laser may yield similar or greater results to
the 1,450 nm diode laser.
Infrared laser-1,540 nm Erbium: Glass (NAFR): The 1,540 nm Erbium:glass
laser (Aramis, Quantel Medical, Clermont-Ferrand, France), like the
SmoothBeam and CoolTouch, also uses contact cooling for epidermal
protection. Unlike theselasers, it has a smaller spot size (4 mm), and therefore
treatments are relatively comfortable and require no topical anesthesia. The
1540 nm erbium:glass laser penetrates to a depth intermediate between
1320 nm (deepest) and 1450 nm (shallowest) and also induces tissue water
heating, thermal injury, and neocollagenesis.
Fournier et al. determined that the erbium:glass laser results in
progressive improvement of perioral and periorbital rhytids at 6 and 14
months. New collagen formation was also noted at the papillary dermis from
biopsy specimens.
Infrared laser-1,550 nm erbium-doped fiber (NAFR): Manstein et al.
performed the rst study of the fractional laser by treating 15 subjects with
varying densities on the distal forearm. Biopsies taken from the treated
sites at 48 hours, 1 week, 1 month, and 3 months were used to help describe
the wound-healing process. Results from this study eventually led to FDA
approval for the use of the fractional laser for soft tissue coagulation in 2003.
Since then, the laser has been sanctioned for the following indications:
periorbital rhytides, pigmented lesions, melasma, skin resurfacing, and
scarring.
This device has been discussed previously in detail and has been the
game changer as it has managed to optimize results and side effects.
In Motion Devices
Near-infrared lasers have been used in a motion technique for skin
rejuvenation. The procedure (Laser Genesis, Cutera, Brisbane, CA) is easy
to perform and results in only mild erythema postoperatively. This 1,064 nm
laser, which has a 5:7 mm spot size is used in a rapid back-and-forth fashion
at 5 Hz and 1215 J/cm2. The device is moved from region to region based on
the surface temperature or patients comfort. Obviously, the lack of anesthetic
is imperative in this approach, as excessive pain must be reported by the
patient and should alert the operator to move and prevent epidermal injury.
Plasma Resurfacing
Plasma resurfacing is a relatively new technology that has been in clinical
use for over 3 years, with 6 years of ongoing trials assessing its efficacy for
facialand non-facial skin rejuvenation. The Portrait PSR system is currently
the only commercially available plasma resurfacing system to date (Kilmer S,
Bentkover SH).
Mode of Action
Plasma skin regeneration (PSR) utilizes energy derived from nitrogen gas to
create heat that is delivered onto the skin surface resulting in zones of thermal
damage and thermal modification. PSR is not chromophore dependent and
does not result in vaporization of the epidermis, as is seen with ablative
lasers, but leaves a layer of intact, desiccated epidermis that acts as a biologic
dressing and promotes rapid healing.
The histological depth of cleavage is directly related to the pulse energy

of the treatment. At settings of 1 J, the line of cleavage extends only to the
superficial most portions of the epidermis and at 4 J, the line of cleavage is
within the papillary dermis (Fig. 7.1).
Dose
Seven treatment protocols are available to treat the full spectrum of patient
conditions. These range from a low pulse energy (0.5 J) lunch hour procedure
with effects and recovery times similar to those of fractional lasers to high
energy (4 J) double pass procedures with more dramatic improvements and
recovery times of 710 days. Protocols are comprised of either single or
multiple treatments that can be matched to the patients condition.
Indications
The PSR has received FDA 510(k) clearance for treatment of rhytides of
the body, superficial skin lesions, actinic keratoses, viral papillomata, and
seborrheic keratosis.
As only one manufacturer for this device is there in the World, there are
issues in procuring spare parts for this device.
The PSR has beneficial effects in the treatment of dyschromias and
photoaged skin, and has been utilized for the treatment of acne scars, eyelid
laxity, Hailey-Hailey disease, and linear porokeratosis.
Contraindications
Patients with keloid prone skin, active infection, breaks in skin or any
cutaneous inflammatory condition, patients who are pregnant or nursing,
those who would be deemed ineligible for general surgery, patients with
Fitzpatrick skin types V and VI, and those patients who have taken oral
isotretinoin within the past 6 months.
Fig. 7.1: Diagrammatic depiction of the depth of the plasma resurfacing device at
various doses. Note that at 1 J, the ablation is superficial, while at 4 J the ablation zone
is till the dermis
Results
Published reports assessing high energy (34 J) single pass PSR for facial
rejuvenation have demonstrated a mean 50% improvement in skin tone
30 days after treatment. Other reports have shown attenuated clinical
improvement over time, e.g. a mean 39% reduction in depth of fine facial lines
at 10 days after treatment that decreased to 23% 6 months after treatment.
The PSR has been also used for acne scars with a 23% reduction in scar
depth at 6 months. Published reports assessing PSR in the treatment of
non-facial skin using low energy settings have demonstrated mean clinical
improvements of 57%, 48%, and 41% in chest, hands, and neck sites,
respectively, and significant reductions in wrinkle severity, dyschromia, and
increased skin smoothness were achieved (Alster TS, Konda S).
Conclusion
Do We have the Ideal Device for Skin Rejuvenation ?
Skin rejuvenation and antiaging have become hot topics with almost all
the major laser companies jumping on to the bandwagon. Excessive skin
exposure to solar UVA and UVB brings about damaging morphological and
metabolic changes in the epidermis and dermal extracellular matrix (ECM),
combining with and accelerating the effects of chronological aging and
resulting in the lax, dull and wrinkled appearance of old skin.
Oxidative stressors such as singlet oxygen, which are generated following
absorption of UV radiation damage the matrix causes elevation of matrix
metalloproteinases (MMPs) 1 and 2 and leads to elastotic damage to the
underlying connective tissue. As this damage is cause by light, an elegant
concept to use the power of light to reverse the damage led to the application
of lasers, usually the CO2 or/and the Er:YAG, in what became known as
ablative laser resurfacing. Although still regarded as the gold standard
in the rejuvenation of severely photoaged skin in general and wrinkles in
particular, the possibly severe side effects and a prolonged patient downtime
of up to several months associated with this approach drastically reduced its
popularity.
To attempt to overcome these problems, so-called nonablative resurfacing
was developed using specially adapted laser or intense pulse light sources.
The theory was to deliver a controlled zone of deliberate photothermal
damage beneath an intact epidermis, so that the wound-healing processes,
including collagenesis and remodeling, could occur under the undamaged
epidermis, thereby obtaining rejuvenation of the skin without any patient
downtime and was popularized as the lunch-break rejuvenation. The theory
was good, but in clinical practice patient satisfaction was very low, (Trelles
MA 2001, Nikolaou VA,2005) because the good dermal neocollagenesis
seen in post-treatment histological analysis was not reflected in a younger

epidermis (Orringer JS).
In an attempt to bridge this gap between ablative and pure nonablative
rejuvenation, so-called fractionated or fractional technology was
developed whereby many spots of almost grossly invisible epidermal
and dermal microdamage were delivered via a scanner or stamp-type
head, all surrounded by normal epidermis and dermis to obtain swift re
epithelialization and dermal wound healing. Unfortunately, once again the
clinical results were not satisfactory to the majority of patients, with good
dermal neocollagenesis not being echoed in the epidermis.
In both, the nonablative laser/IPL and the first generation of fractional
technologies, the big problem was that what the patient first sees when
looking in a mirror is the epidermis, not the dermis. It does not matter to
the patient (or her friends) that her dermis is wonderfully better organized
if her epidermis remains unchanged, what Dr Glen Calderhead refers to as
the SOE syndromesame old epidermis. Recognizing this, manufacturers of
the more recent second generation of fractional systems have returned to the
orginal ablative wavelengths, the CO2 and the Er:YAG, in addition to newer
media such as Er-doped fiber, to deliver fractionated microbeams that visibly
damage the skin, with a recognizable amount of erythema and some edema
post-treatment.
Thus, we have reinvented the wheel so as to speak and gone back to
our gold standard of ablative resurfacing. This approach has been much more
successful from the patient satisfaction criterion, although at the cost of a
little downtime, because it is involving the epidermis more than the previous
nonablative and fractional approaches.
How to Choose the Right Device ?

The first rule to remember is that no single device can tackle all the problems
of a photodamaged skin and secondly dramatic responses are hard to come
by and should not be promised to the patient.
When selecting a thermal photorejuvenation system, it is therefore critical
to understand the physics behind the wavelength and the method of delivery
rather than exaggerated manufacturers claims. Having knowledge of the
output of a device, understanding whether the target is hemoglobin, melanin
or water (or all three) and understanding spot size and method of delivery,
the physician may be better able to choose the correct system for the correct
application.
For example, photorejuvenation of pigmented lesions would not be
possible with a unit emitting 1,450 nm, for which the target is water and not
melanin. This knowledge is also vital if the clinician is to minimize possible
adverse clinical events in darker ethnic skin types. Visible light, more strongly
absorbed by melanin, must therefore be used with greater caution in darker
skin. A patient concerned about excessive telangiectasia, would be better

served by the 532 nm potassium titanyl phosphate (KTP), a PDL, or an IPL
device. If the goal is to obtain deeper dermal remodeling, one of the many
infrared devices may be needed.
An approach to specific patient problems with specific treatments is
outlined in Box 7.2.
Thus, in clinical practice a combination of laser devices is needed for
optimal results (Box 7.2). As the relative benefits of individual devices
within in each indications have not compared to determine the ideal device,
this leaves this field open to research. Numerous other issues have to be
considered some of which are given in Box 7.3.
Clinical evaluations of nonablative and minimally ablative therapy
generally rely on patient and physician (blinded and nonblinded)
assessments of before and after photographs. Additional objective methods
of skin texture measurement include prolometry and ultrasound, among
others. Differences in before and after results can be subtle, even with the
use of digital photography. Though most of the studies in literature have
used these parameters some clinicians are not satisfied by the end results.
But these therapeutic interventions remain popular among both patients
and physicians, suggesting that although differences may not always be clear,
results are real. Determining which patients are suitable for skin resurfacing
depends in part on the patients desires and expectations with treatment.
Box 7.2 A summary of the use of laser/light for treating photodamaged skin
Morphology
Devices used
Telangiectasias
IPL
PDL LP
Nd:YAG (LP 532 nm)
Diffuse-redness (nonvisible telangiectasia)
IPL
LED photomodulation
Mottled pigmentation
IPL
Nd:YAG (LP) 532 nm
LED
Mild rhytides
LED photomodulation
IPL
PDL
Nonablative infrared lasers
Moderate rhytides
Infrared lasers
Deeper rhytides
1,320 nm,1,450 nm, 1,540 nm

RF
Acne scars
Erythematous: IPL, PDL, LED

Nonerythematous: 1,320 nm, 1,450 nm,
1,540 nm IPL, LED
Texture
532 nm, PDL, Qs Nd:YAG IR laser, LED

Box 7.3 Miscellaneous aspects relevant to nonablative lasers
Ideal patient
Glogau grade II or III with mild to moderate

photodamage
Dark skin type
Mid-infrared lasers, Avoid light based devices
Fillers and botox
Should precede subsurface laser procedure by 1 hours
Pain
More with IR devices
Edema
More PDL, IPL, or Nd:YAG
Contraindications
Active dermatitis or infection

History of keloid/hypertrophic scar formation
History of koebnerizing dermatitis (psoriasis, vitiligo)
History of photosensitive dermatitis
History of oral retinoid use (12 month)
Recent medium or deep chemical peel

Patient selection is important here as this is one indication where the
expectation-outcome is crucial.
Thus, it is better to give less expectation to the patient so that the end
results achieved are satisfactory!
Patient Selection
The ideal patient is a relatively young patient (2565 years of age), with
minimal facial skin sagging, and should be made aware that skin texture and
ne lines will improve, but will not be eliminated. Furthermore, since the
effects of treatment are cumulative, it is important to reiterate that multiple
treatments will be more benecial than a single treatment.
Pre-procedure
The physician should always obtain pre-treatment photographs. The patient
should be placed and draped in a position that allows full access to the
treatment area. This is typically achieved by placing the patient in the supine
position to treat photodamaged areas, such as the face, neck, chest, and
forearms. Appropriate goggles or eye shields (internal or external depending
on the treatment area) are then applied to assure proper ocular protection.
It is helpful to inform the patient who has appropriate eye protection about
the likelihood of seeing a flash of light during the procedure. Many patients
become anxious regarding the dangers of lasers when they see a flash of light
even when they have goggles or shields over their eyes. Informing them that
they are adequately protected, even when they see a flash of light adjacent to
the shields, puts them at ease.
Procedure
It is difficult to detail the various settings required to operate the devices
given in Box 7.3. Thus, an individulized approach is needed.
But for pigmented skin, it is our view that most of the light based devices
should be used with care and the infrared and RF help the patients more than
vascular, IPL and PDL devices.
Bibliography
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and device selection. Skin Therapy Lett. 2003;8(4):4-7.
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1. Alster TS, Konda S. Plasma skin resurfacing for regeneration of neck, chest and
hands: investigation of a novel device. Dermatol Surg. 2007;33(11):1315-21.
2. Bentkover SH. Plasma skin resurfacing: personal experience and long-term
results. Facial Plast Surg Clin North Am. 2012;20(2):145-62.
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reported long-term therapeutic efcacy associated with 1,320 nm Nd:YAG laser
treatment of acne scarring and photoaging. Dermatol Surg. 2006;32:346-52.
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intense pulsed light treatments. Dermatol Surg. 2000;26:835-43.
5. Boulos PR, Kelley JM, Falcao MF, et al. In the eye of the beholder skin
rejuvenation using a light-emitting diode photomodulation device. Dermatol
Surge. 2009;35(2):229-39.
6. Chan HHL, Lam L, Wong DYS, et al. Use of 1,320 nm Nd:YAG laser for wrinkle
reduction and the treatment of atrophic acne scarring in Asians. Lasers Surg
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7. Cisneros JL, Rio R, Palou J. The Q-switched neodymium (Nd):YAG laser with
quadruple frequency. Clinical histological evaluation of facial resurfacing using
different wavelengths. Dermatol Surg. 1998;23:345-50.
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ultrasound imaging and prolometric evaluation of a 1540 nm Er:glass laser.
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laser. Dermatol Surg. 1997;23:9037.
10. Kilmer S, Semchyshyn N, Shah G, Fitzpatrick R. A pilot study on the use of
a plasma skin regeneration device (Portrait PSR3) in full facial rejuvenation
procedures. Lasers Med Sci. 2007.
11. Lee SY, Park KH, Choi JW, Kwon JK, et al. A prospective, randomized, placebocontrolled, double-blinded, and split-face clinical study on LED phototherapy
for skin rejuvenation: clinical, profilometric, histologic, ultrastructural, and
biochemical evaluations and comparison of three different treatment settings. J
Photochem Photobiol B. 2007;88:51-67.
12. Lipper GM, Perez M. Nonablative acne scare reduc-tion after a series of
treatments with a short-pulsed 1,064-nm neodymium:YAG laser. Dermatol Surg.
2006;32:998-1006.
concept for cutaneous remodeling using microscopic patterns of thermal injury.
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light with objective measurement of skin color in Japanese patients. Dermatol
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Dermatol. 2005;4:301-7.

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remodeling after nonablative laser therapy. J Am Acad Dermatol. 2005;53:77582.
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Nd:YAG laser in the treatment of atrophic facial scars: a prospective clinical and
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Chapter
Nonsurgical Tightening
Simal Soin, Kabir Sardana
Introduction
Numerous attempts have been made at counteracting the signs of aging, such
as redundant facial and neck skin. In terms of skin laxity specifically, the gold
standard of treatment remains rhytidectomy or surgical redraping. However,
with the recent advances in technology, conditions that once required major
surgical intervention may not always require aggressive intervention. Though
nonablative lasers (long pulse 1,064 nm Nd:YAG), and fractional lasers
have been used, radiofrequency (RF), infrared, and ultrasound devices are
probably better, though the last is yet to find universal acceptance (Table 8.1).
Radiofrequency energy works to tighten and lift tissue by delivering heat
to dermal structures without adversely affecting the epidermis, thus making
it an ideal choice for the nonsurgical face-lift. This energy is produced by an
electric current that does not diminish by tissue scattering or absorption by
a chromophore. Light-based treatments such as lasers and infrared devices
rely on chromophores to produce antiaging effects.
Ultrasound waves induce molecules in deep tissue to vibrate, resulting
in tissue heating. Like RF energy, the ultrasound waves spare the epidermis
Table 8.1 Overview of devices for skin tightening
Device
Skin tightening mechanism
ThermaCool TC
Monopolar RF
Accent
Bipolar RF and unipolar RF
Rerme ST
IR and bipolar RF
Polaris WR
Monopolar RF and diode

laser (910 nm)
Titan
IR
Lux-IR
Fractional IR
GentleYAG
Long-pulse Nd:YAG
USG
Ulthera
Nonsurgical Tightening 295
and cause selective heating of the deeper tissues. We will focus on minimally
invasive, nonablative tissue tightening techniques, including radiofrequency,
light and ultrasound-based devices. These devices are not a replacement for
surgical procedures and appropriate patient selection remains key to overall
satisfaction.
Radiofrequency
Therapeutic use of RF technology was rst introduced by Bovie and Gushing
in the 1920s with the advent of electrocautery. Since then, it has been used for
a variety of medical purposes. The discovery that this energy could penetrate
deep into the dermis and brous septae that support underlying structures
via the emission of high-frequency radio waves suggested that this technology
could also be used to lift and tighten aging skin.
Apart from the three major subtypes, monopolar, bipolar and unipolar RF,
some devices that are labeled to be tripolar or multipolar but are variations of
the basic three forms of monopolar, bipolar, or unipolar (Table 8.2).
Combination Devices
Recently, devices combining RF and light systems were introduced in an
attempt to treat both skin laxity and rhytides. These include the ReFirme ST
and the Polaris WR systems. ReFirme ST combines broadband IR (7002,000
nm) and bipolar RF energies (70120 J/cm3), while the Polaris WR TM system
(Syneron Medical Ltd, Israel) combines RF and 900 nm diode laser energies,
known as electro-optical synergy or ELOSTM. The optical energy component
is used to selectively heat the target tissue. Other energy sources, such as
laser or intense pulsed light, can be combined with RF so that a large array of
technologies use RF for the ultimate goal of smoothing and tightening of the
skin (Table 8.2).
Principles of RF
It accomplishes its tissue tightening effects via a unique scheme that utilizes
MRF energy at a wavelength of 6 MHz. The energy is applied to the skin
via a handpiece that contains a single-use electrode tip. A thin capacitive
membrane located on the electrode couples RF to the skin by distributing
RF energy (in the form of an electrical current) over a volume of tissue under
the surface membrane. A return electrode is placed at a distant site on the
body, usually on the back, and an electromagnetic eld is created that rapidly
alternates from positive to negative charge. As charged molecules pass
through the electrical eld, heat is generated by the resistance of dermal and
subcutaneous tissues to the passage of the electric energy (Fig. 8.1A).

Table 8.2 Comprehensive classification of RF devices*
Company and
device
Energy specifications
Tips/
electrodes
Comments
Biorad
GSD Tech Co,
Shenzhen,
China
1.15 MHz
1,000 W
3 tips
Continuous cooling; automatic

resistance technology; single and
continuous mode
Cutera
TruSculpt,
Brisbane, CA
1 MHz
4 handpiece
Handpiece reads out once

optimal temperature is reached
of
4345 C
Ellman
Pelleve,
Oceanside, NY
4 MHz
4 small handpieces
7.5, 10, 15, 20
mm
Several handpieces for smaller

areas. Can use unit as an
electrocautery unit also
RF + Cautery
Thermage
Solta Medical,
Hayward, CA
6.78 MHz
400 W
New handpiece (CPT:

Comfortable Pulse Technology)
with vibrations to improve
patient comfort. Pain nerval
interceptors get confused
and busy (vibrations, cooling,
heating)
Accent Family
Alma Lasers,
Caesarea, Israel
40.68 MHz
Up to 300 W
Unipolar+ bipolar+ fractionated

RF
Aluma
Lumenis Ltd.,
Yokneam, Israel
40.68 MHZ Up to
300 W
Bipolar and
Unilarge
handpieces
Apollo-TriPollar
Pollogen,
Tel Aviv, Israel
1 MHz 50 W
3 handpieces
Aurora SR
Syneron/
Candela,
San Jose, CA
Up to 25 J/cm2
400980 nm
580980 nm
680980 nm
Elos Plus
Syneron/
Candela,
San Jose, CA
13 HZ
Variable
eMatrix
Syneron/
Candela,
San Jose, CA
Up to 62 mJ/pin
Monopolar
Devices
Bipolar RF
FACES technology using

functional aspiration
RF + IPL
RF + Infrared light
Matrix of
electrodes
Fractional RF
Disposable tip, which can prove

to be a disadvantage over
conventional fractional lasers
Contd...

Contd...
Company and
Device
Energy
specifications
Tips/electrodes
Comments
EndyMEd PRO 3
Deep 3 Pole
EndyMEd
Medical,
Caesarea, Israel
1 MHZ 65 W
4 handpieces
3 Deep RF, Handpieces: Skin

tightening, body contouring,
facial tightening, fractional skin
resurfacing
Eprime Syneron/
Candela,
San Jose, CA
460 kHZ
84 VRMS
Microneedles
20 degree delivery angle,

injected into dermis, fractional
skin resurfacing
eTwo
Syneron/Candela,
San Jose, CA
62 mJ sublative;
100 J/cm3
sublime
Matrix of
electrodes
RF + IR
Ray Life
Ascepelion
0.5-1 mHz
3 handpieces
Suction and three modes
Reaction
Viora,
Jersey City, NJ
0.8, 1.7, 2.45

MHz
Body 50 W
Face 20 W
4 modes- 0.8, 1.7,

2.45 and
multichannel
SVC (suction, vacuum, cooling)

devices
TiteFx
Invasix, Yokneam,
Israel
1 MHz 60 W
VelaShape II
Syneron/Candela,
San Jose, CA
Infrared- Up to
35 W RF
Up to 60 W
Velasmooth
Syneron/Candela
7002,000 nm
Venus Concept-8
Circular Poles
Venus Freeze,
Toronto, ON
RF: 1 MHz
Magnetic
pulse: 15 Hz
RF: up to 150-W
Magnetic flux:
15 Gauss
V-Touch
Viora, Jersey City,
NJ
Bipolar w/suction real time

epidermal temperature monitor
Handpiece with
bipolar
Radiofrequency,
Infrared laser,
Suction
Vsmooth (40 mm 40 mm) and

Vcontour (30 mm 30 mm)
treatment areas
RF/Infrared light with

mechanical manipulation
Large hand
piece 8
poles 5 mm
apart,
dual mode =
bipolar
magnetic field
Multipolar RF and magnetic

pulse
3 hand
piece-0.8,1.7,
2.45
SVC (suction, vacuum, cooling)

devices
1 handpiece
Unipolar energy to heat fat,

bipolar to deliver energy to
dermis
Non Contact
Operator independent
Unipolar RF
Accent RF
Alma Lasers,
Caesarea, Israel
40.68 MHz Up to
200 W
Multipolar
Devices
Vanquish
BTL Aesthetics,
Prague, CR
*Please contact manufacturers for procedural details
The devices energy output is calculated using the following formula:

Energy (J) = I2 z t
where I is current, z is impedance, and t is time in seconds. Energy (J) is
created by the impedance ( z ) to electron movement relative to the amount
of current ( I ) applied and the total time ( t ) that current is delivered to the
tissue. The heat generated is in the temperature range of 6575C, which can
cause collagen damage, induction of an inammatory response, thereby
resulting in skin lifting and tightening (Fig. 8.1B).
Mode of Action
Monopolar RF (Thermage) causes immediate skin tightening through
collagen contraction since it heats the collagen in the dermis and fibrous
septae in the subcutaneous fat layer. The body interprets the heat as a wound
and results in wound healing over a period of time. The wound healing
response results in clinical skin tightening. Patients have improvement in
Fig. 8.1A: A diagrammatic overview of the mode of delivery of RF in Thermage. The

electrical current passes through a single electrode in the handpiece to a grounding
pad. There is a high density of power close to the electrodes surface with the potential
for deep penetration of tissue heating
Fig. 8.1B: Illustration of the mechanism of collagen remodeling due to RF
superficial laxity through collagen tightening in the dermis and subcutaneous

laxity through tightening of the fibrous septae in the subcutaneous layer. To
denature collagen requires heating the tissue to a therapeutic temperature
and then keeping it at that temperature.
The thermal effect causes the collagen to denaturize and this is transposed
into a breaking of the intramolecular bonds. Thus, the molecular structure of
collagen is therefore shorter and thicker, which translates into a tensor effect
that is visible and palpable (skin tightening). The thermal shock produces on
the fibroblasts an increase in the production of physiological collagen.
It should be emphasized that this very heat can produce problems if too
much heat is delivered as the collagen fibrils will denature completely above
a critical heat threshold. Conversely, if too little heat is delivered, there will be
no tissue response, although it appears that mild thermal injury gives rise to
new dermal ground substance and tissue remodeling of photodamaged skin
over time. The optimal shrinkage temperature of collagen has been cited as
5761C; however, contraction is in actuality determined by a combination
of temperature and exposure time. For every 5C decrease in temperature, a
tenfold increase in exposure time is needed to achieve an equivalent amount
of collagen contraction.
The other main mechanism in skin rejuvenation is a secondary wound
healing response that produces dermal remodeling over time. The wound
healing response entails activation of fibroblasts to increase deposition of
type I collagen and encouraging collagen reorganization into parallel arrays
of compact fibrils.
Variables that Affect RF Penetration

With radiofrequency technologies, the depth of energy penetration depends
on the configuration of the electrodes (i.e. either monopolar or bipolar), type
of tissue serving as the conduction medium (i.e. fat, blood, skin), temperature,
and the frequency of the electrical current applied.
Tissue is made up of multiple layers, which have different resistances to
the movement of radiofrequency energy with the dermal tissue with higher
impedance being more susceptible to heating. As a thumb rule fat, bone,
and dry skin tend to have low conductivities, thus the current tends to flow
around these structures rather than through them. Wet skin has a higher
electrical conductivity allowing greater penetration of current. This is the
reason why improved results are seen with generous amounts of coupling
fluid and increased hydration of skin. The structure of each individuals tissue
(dermal thickness, fat thickness, fibrous septae, number and size of adnexal
structures) all play a role in determining impedance, heat perception, and
total deposited energy despite otherwise equal parameters.
Temperature also influences tissue conductivity and the distribution
of electrical current. Generally, every 1C increase in temperature lowers
the skin impedance by 2%. Surface cooling will increase resistance to the
electrical field near the epidermis, driving the radiofrequency current

into the tissue and increasing the penetration depth. In addition, target
structures that have been pre-warmed with optical energy will, in theory,
have greater conductivity, less resistance, and greater selective heating by
the radiofrequency current. This is the advantage of hybrid skin-tightening
devices that use a combined approach of light and radiofrequency energy
together giving synergistic results.
Monopolar Devices
Monopolar devices may be delivered in a static or stamped mode in which
a short 1- to 2-second cycle is delivered while the handpiece is held in
place (Thermage, Solta Medical, Hayward, CA). Alternatively, monopolar
RF may be delivered in a dynamic or a continuous pulse with constant
rotation of the handpiece (Exilis, BTL, Prague, Czech Republic). In the static,
stamped method, a single pulse is delivered; the handpiece is then moved
to an adjacent marked area and fired again. This technique is performed for
hundreds of pulses until a premarked area is treated. Each pulse is measured
for temperature while spray cooling is applied so that a skin temperature of
45o C is not exceeded.
With dynamic monopolar RF, the handpiece is continuously moved
and specific areas of laxity can be targeted in a relatively short time to a
final temperature that is monitored by continuous surface temperature
measurements.
Thermage
It was the rst nonsurgical treatment of periorbital skin laxity and rhytides
approved by the FDA and has since become a common technique for treating
aging skin (mid-face, cheeks, jaw line, neck, brows, abdomen, legs, and
thighs).
Thermage has been backed by a strong research and development; and
now in its third generation, it has evolved into an extremely sophisticated
device. The first generation device, was called thermacool NXT device which
employed 400, 600 and 900 REP (Radiofrequency Energy Pulse) disposable
tips with a heat and cooling sensation.
The next level is the Thermage CPT, which has some features that make it
superior to the previous NXT (Figs 8.2A and B).
1. Redesigned tip, which improves uniformity of heating and increases the
total area of skin being effectively heated.
2. Comfort software intended to simulate transcutaneous electrical nerve
stimulation (TENS) pain reduction therapy. The TENS therapy for pain
management is based on the principle that when electrical current is
delivered through the skin, electricity stimulates nerves in the affected
Fig. 8.2A: Overview of the Thermage device
Fig. 8.2B: A closer look at the components of Thermage
area and sends signals to the brain that scramble normal pain perception.
In effect, the pulsed behavior of the radiofrequency interwoven with
cooling bursts improves patient comfort.
3. Vibration based on the gate control theory of pain mitigation. The new
thermage CPT handpiece vibrates the tips in order to mitigate discomfort.
This Thermage solution here is based on the gate theory by Melzack and
Wall, which states that nerve fibers carrying pain to the spinal cord can
have their input modified at the spinal cord before transmission to the
brain, in this case by the vibration.
CPT (Comfort Pulse Technology) system came with features that

maximized thermal distribution and patient comfort both thereby
giving better tightening and contouring (Fig. 8.2C). The third generation
thermage employs the same vibration delivery module but with the new
total tip which has even more homogeneous three-dimensional skin
tightening. These variously sized tips depend mostly on the anatomical
area being treated, as larger tips cover a larger area of skin. For example,
a 1.5 cm 2 tip should be sufcient for the treatment of the face and neck.
Mechanism of Tissue Heating

The mechanism of tissue heating through the use of monopolar
radiofrequency in thermage is unique (Fig. 8.3). As in conventional RF
devices, the tissue heat is generated based on the tissues natural resistance to
the movement of ions with the RF field but the difference lies in the method
of coupling the RF to the skin. In thermage, a capacitive coupling membrane
is used, which transforms RF to a volumetric tissue heating device rather
than a single point heating source as in standard RF devices. This allows
energy to be distributed over a three-dimensional volume of dermal tissue
while protecting the epidermis (Fig. 8.4). The use of capacitive rather than
conductive coupling is important because it allows the energy to be dispersed
across a surface to create a zone of tissue heating. With conductive coupling,
the energy is concentrated at the tip of the electrode, resulting in increased
heating at the contact surface and an increased risk of epidermal injury.
Fig. 8.2C: A comparison of third generation RF with the conventional RF
Fig. 8.3: A depiction of the depth of penetration of Thermage
Fig. 8.4: Difference in the heat generation of Thermage and other RF machines
Thermage heats tissue more deeply and to higher temperatures than

other technologies. Temperatures are higher by 34 and deep heating means
that the heat dwells longer in the tissue.
The treatment protocol involves marking square grids on the area to be
treated so that the requisite amount of overlap be done to ensure complete
coverage. The tip delivers monopolar radiofrequency to the lower layers of
the skin while protecting the epidermis with cryogenic cooling. With the new
total tip technology, thermage tightens and smoothens close to the surface
and contours deeply (Figs 8.5A and B).
Although, delivering higher energies translates to better results, it is not
meant to be an extremely painful or uncomfortable treatment, especially
since pain threshold is relative. One may be extremely comfortable with a
treatment energy of 4.5 while another may be uncomfortable with an energy
Figs 8.5A and B: A customized grid is placed to accurately localize treatment doses
of 3.5. Most treatment protocols across the world follow an algorithm of

multiple passes and moderate energies.
Treatment
Patient Selection
Suitable Candidates: Anyone between the ages of 30 and 60 years is a
suitable candidate for the face. For body treatments, anyone from 25 years
onward with a loose sagging skin or cellulite is suitable.
Exclusion Criterion
Although, Thermage is an extremely safe treatment there are a few absolute
and relative contraindications.
Absolute
Pacemakers
Defibrillators
Pregnancy
History of skin cancer, radiation therapy or metal implant in the
treatment area.
Relative
History of diabetes, collagen disorders and congestive heart disease
Patients on blood thinners
Patients on oral retinoids
Recent filler treatments
History of neurological disorders.
Photography: The importance of photographic documentation in all
aesthetic treatments cannot be overemphasized. In Thermage, the results
are subtle and subjective improvement cannot always be appreciated by the
patient so before and after it is helpful to assess results for both the patient
and the doctors.
Anesthesia: The protocol dictates that anesthesia is not required since a
feedback on the pain sensation is important to minimize risk of burns. Also
topical anesthesia does take away from the heat or pain sensation much since
the heat penetration is deep.
Procedure
Treatment Energy
The treating physician must control the amount of radiofrequency energy
balancing patient comfort with optimal results since topical anesthesia is not
utilized for the procedure. The heat sensation from a single pulse treatment
lasts from 27 seconds. Treatment parameters vary across clinics and study
groups, but in general the previous higher energy, fewer pass practice has
now shifted to lower energy and higher pass protocols in order to increase
efciency, tolerability, and safety.
Before treatment is initiated, coupling uid should be applied generously
to the area. Then, following the low energy, high pass protocol, RF energy
should be applied. Initially, it is helpful for the practitioner to make use of
the company-supplied grid that is applied to the skin prior to treatment. The
grid shows exactly where the handpiece tip should be placed for adequate
treatment (Figs 8.5A and B). As an additional fail-safe, the tip must be in
complete contact with the skin or an error message will be displayed. This
ensures that the cooling tip will prevent epidermal disruption.
Treatment Areas
Thermage is primarily used for skin tightening on the face particularly the
jawline, hooding of the eyelids, back of the hands, abdomen, thighs and
upper arms. The best results are seen on the face. The results in the neck are
suboptimal because the skin of the neck is very thin, so delivery of adequate
energy for optimal results is not possible.
Post-care
There is no specific post-care advised following Thermage.
Side Effects
Except for being an expensive treatment because of the disposable tip costs
involved, a Thermage treatment done in trained hands remains an extremely
safe treatment with no side effects whatsoever. Thus, it has managed to stand
the test of time and withstand competition with all the multiple technologies
available.
Results
Initially for the face two passes at 107 J, followed by three or more passes at
83 J was administered. Extra care is given to the neck region, so only 3 or 4
total passes are made at an energy level of 83 J. Moreover, it was noted that
multiple treatments yield signicantly better results than a single treatment
of the nasolabial folds. It is important to continuously assess the patient
for signs of discomfort, swelling, and skin tightening during the procedure.
Another regimen as proposed by Weiss et al. is a multiple pass regimen with
fluences of 74 to 130 J/cm2 using a 1.0-, 1.5-, or 3.0-cm2 tip.
In 2006, Dover and colleagues compared the original single-pass, highenergy technique with the updated low-energy, multiple-pass technique
using immediate tissue tightening as a real-time end point. With the original
treatment algorithm, 26% of patients saw immediate tightening, 54% observed
skin tightening at 6 months, and 45% found the procedure overly painful.
With the updated protocol, 87% had immediate tissue tightening, 92% had
some degree of tightening at 6 months, only 5% found the procedure overly
painful, and 94% stated the procedure matched their expectations. According
to several authors, a good clinical response remains the most useful cut-off
guide for treatment.
Generally, improvements are immediately visible and continue for up to
6 months. One of the key features of a Thermage treatment is the preventative
aging aspect that is not possible with any injectable treatment. The results can
easily last up to 2 years.
Quantiable changes have been seen in brow and superior palpebral
crease elevation as well as in the peak angle of the eyebrow and jowl surface
area.
Site Specific Improvement

1. Face: The effect is a smoothning and tightening of the skin. There is a
improved jawline contouring and sagging of the skin under the chin.
The Figuer 8.6 reveals softening of wrinkles around the mouth, eyes, and
forehead.
2. Eyes: There is a pronounced lifting of the eyelids (Fig. 8.7). Thermage is
probably the only nonsurgical procedure that smoothens and tightens
the skin and decreases wrinkles and hooding in the eye area without
surgery, injections or downtime. Treatment results are younger looking,
more lifted eyes that look less tired. There is reduction in under eye
bulges and improved laxity. Eyes are protected during the procedure
Fig. 8.6: A marked improvement in the forehead lines
Fig. 8.7: A pre- and postoperative photograph showing the marked improvement in
wrinkles around the eyes
with small, plastic eye shields. Suitable candidates for thermage for
eyes are those with moderate hooding, crows feet, eyelid laxity and/or
under-eye bags.
3. Body: Thermage for the body procedures improve skin tone and texture
while effectively smoothing, tightening and contouring skin for an overall
naturally younger looking appearance. With little to no downtime,
thermage for the body treatments tighten and renew the skins collagen
deep down, through all three layers of skinthe epidermis, dermis
and subcutaneous (fat) layer. The treatment is ideal for arms, abdomen
(commonly used post-pregnancy and after liposuction or weight loss),
and thighs. It remains the nonsurgical treatment of choice for loose lax
skin on the body areas (Fig. 8.8).
Cellulite
Thermage is FDA approved for cellulite. Although it is widely used with a
separate cellulite tip, in the authors experience the results are variable.
Acne
In addition to skin tightening, monopolar RF has also been used to treat active
cystic acne to inhibit sebaceous activity and promote dermal contouring. A
study (Ruiz-Esparza J 2003) including 22 patients with moderate to severe
active cystic acne reported improvement with the use of stamped monopolar
RF. Patients were treated in 1 to 3 sessions using 65 to 103 J/cm2. A 75%
reduction in the active acne lesion count was seen in 92% of patients, and a
25% to 50% reduction occurred in 9% of patients. Often a decrease in active
lesions was accompanied by the improvement of underlying scarring. These
results have not been duplicated in other studies.
Fig. 8.8 : Tightening of the loose skin on the abdomen
EXILIS Elite Device

A novel RF dynamic monopolar device, the Exilis, is a device that combines
focused monopolar RF delivery with several built-in safety features, including
Peltier cooling. The Exilis system delivers the energy through two different
hand applicators, one designed for the face and one designed for the body.
The goal of treatment is to raise the surface temperature to 40C to 42C for 4 to
5 minutes for each region treated. When this temperature is reached, patients
feel a comfortably warm sensation. The handpiece is in continuous motion
so that the areas of skin with the most laxity can be specifically targeted. This
treatment has been termed dynamic monopolar RF. Additionally, Peltier
cooling can be adjusted up or down to allow targeting of skin or subcutaneous
tissue. For example, to drive heating more deeply, the skin is cooled and
protected allowing heat to reach into subcutaneous fat. Alternatively, to get
the maximum effect on skin laxity, cooling is turned off and heating of the
skin occurs very quickly with a minimal effect on subcutaneous fat.
Bipolar RF
In this method, the RF travels from the positive to the negative pole,
which is typically between 2 poles built into the handpiece. With a specific
distance between the electrodes, the depth of penetration and heating is
predetermined by the spacing of the electrodes and is typically confined to
within 1 to 4 mm of the skin surface (Fig. 8.9). It is commonly stated that the
depth of penetration is half the distance between the electrodes, but there is
very little evidence to support this assertion.
The Raylife radiofrequency is bipolar parallel that uses a handpiece that
has two electrodes positioned inside it.
The addition of the vacuum function generates continuous or pulsed
suction of tissue with the passage of electromagnetic waves only on the
selected target area. These waves pass from one electrode to another and
when they cross the dermis they activate the mechanism of denaturizing the
collagen. The Coolstar, water cooling function on the tissue, determines a
protective action on the epidermis making the treatment extremely pleasant
and safe (Fig. 8.10).
Bipolar RF is not as penetrating as monopolar RF, so it is not as painful but
is often combined with another energy source to increase its efficacy. There
are multiple variations of the bipolar RF concept and these are as follows
(Table 8.2):
1. Fractional or fractionated RF constructed of mini-bipolar electrodes
(eMatrix, e2, Syneron/Candela, Wayland, MA).
2. Bipolar insulated needle electrodes, which are mechanically inserted
into the dermis (ePrime, Syneron/Candela).
Fig. 8.9: Illustration of bipolar radiofrequency, L handpiece (inactive and active)

(Asclepion Laser Technologies, GmbH)
Fig. 8.10: Advantages of bipolar RF (Asclepion Laser Technologies, GmbH)
3. Bipolar RF combined with other modalities, including diode laser

or intense pulsed light (Polaris, Aurora, and Velasmooth, Syneron/
Candela).
4. Multiple bipolar electrodes at different distances apart firing sequentially
to achieve different depths (EndyMed PRO, EndyMedMedical Ltd,
Caesarea, Israel).
5. Bipolar RF with vacuum to control depth of penetration called functional
aspiration controlled electrothermal stimulation (Aluma, Lumenis Inc,
San Jose, CA).
6. Other variations include magnetic pulse and combinations with IR.
The major disadvantage to bipolar radiofrequency is that the energy
does not penetrate very deep into the skin. Also, it is believed that bipolar
radiofrequency is unable to produce a uniform, volumetric heating response
comparable to monopolar radiofrequency. When bipolar radiofrequency
devices are combined with other light-based technologies, which is the case
in most situations, it is then difficult to assess exactly how large a role bipolar
radiofrequency plays in the clinical outcomes of such treatments.
Aluma
The Aluma is a bipolar RF plus vacuum device that is composed of an RF
generator, a handpiece, and a tip with 2 parallel electrodes. When the hand
piece with the tip is placed perpendicular to the surface of the skin, the system
produces a vacuum, which suctions a small area of skin. The skin becomes a
U-shaped area with epidermis on both sides and the dermis and connective
tissue in the middle. The design is to allow the energy emitted to reach the
middle and deep dermis.
This is also called as FACES (functional aspiration controlled electro
thermal stimulation) technology. Non-target structures such as muscle,
fascia, and bone are avoided. The theory is that this may help to overcome
the depth limitations inherent in bipolar radiofrequency technology by
bringing the target tissue closer to the electrodes. Less overall energy may
also be required for an effective treatment. It has also been hypothesized that
increased blood flow and mechanical stress of fibroblasts from the vacuum
suction may lead to increased collagen formation. Vacuum technology has
the added benefit of helping to reduce procedure discomfort.
In a pilot study of 46 adults, Gold found significant improvements in skin
texture, indicating a shift from moderate to mild elastosis. There was a shortterm tightening effect due to collagen contraction followed by a gradual, longterm improvement due to the wound healing response and neocollagenesis.
Importantly although subjects were generally pleased with the treatment
outcome, their satisfaction levels declined somewhat during the follow-up
period.
eMatrix
Fractional RF is another form of bipolar RF delivery with mini-electrodes. The
concept is that RF is omnidirectional so that dots of RF spread out from the
point of contact in comparison with laser in which the energy is attenuated in
a sharp fashion in interaction with tissue.
Fractional RF has been used mainly for skin rejuvenation. Less than
1-mm thermal injuries are formed in a patterned fractional array directly to
the reticular dermis. The area directly in contact with and below the array of
microneedles or electrodes is selectively heated while the areas between the
targeted areas are left intact.
ELOS
Combined Electrical and Optical Energy
The basic principle is that these skin-tightening devices combines radio
frequency energy with optical energy from laser or light sources. The currently
available combined electrical and optical energy devices include the Galaxy,
Aurora, Polaris, and ReFirme systems (Syneron Medical Ltd, Yokneam,
Israel).
They have a theoretical advantage of acting synergistically to generate
heat. As discussed above when the target structures have been pre-warmed
with optical energy they will have greater conductivity, less resistance, and
greater selective heating by the radiofrequency current. No grounding pad is
required as the current flows between the electrodes rather than throughout
the remainder of the body as with monopolar systems. There is a potential
side effect in tissue arcing, which results in tissue burns and possible scar
formation. Proper technique will help avoid the issue as arcing has been
associated with the handpiece not being properly placed in contact with the
skin.
The technology has been used in hair removal, wrinkle reduction, skin
tightening, and the treatment of both pigment and vascular disorders. The
premise is that less radiofrequency energy is ultimately needed for proper
collagen denaturation and remodeling.
The ReFirme ST system produces only mild improvement of facial laxity in
Asians (Yu et al.) without serious adverse effects, but still meets high patient
expectations. More enduring studies are necessary to determine the longterm tissue tightening effects of this device.
A study by Doshi and Alster in 20 patients (skin phototypes IIII) with
mild-to-moderate rhytides and skin laxity with the Polaris WR combination
RF and diode laser device found only modest improvement of facial
rhytides.
Hybrid Monopolar and Bipolar Radiofrequency

The first system to combine monopolar and bipolar radiofrequency in one
device was the Accent (Alma Lasers, Buffalo Grove, IL). The theory behind
using both types of radiofrequency is to deliver different depths of current to
the skin. The bipolar electrode handpiece allows for more superficial, localized
(non-volumetric) heating based on tissue resistance to the radiofrequency
conductive current. The monopolar electrode handpiece targets deeper,
volumetric heating via the rotational movement of water molecules in the
alternating current of the electromagnetic field.
Therefore, the monopolar handpiece is used to treat the forehead, cheeks,
jawline, and neck while the bipolar handpiece is used to treat the glabella,
lateral periorbital area, upper lip and chin, and leg.
In 2007, Friedman and Gilead studied this device and found that although
the Accent system is effective in the treatment of wrinkles and lax skin,
younger individuals may see a greater benet.
Pelleve Device (Ellman International, Oceanside, NY)

This has a dual monopolar and bipolar radiofrequency-based surgical unit
normally used for tissue cutting and coagulation to make it suitable for skintightening procedures. The system works with the use of reusable probes that
are plugged into the system and applied over the skin in a circular pattern
to heat the subdermal tissue. A chilled coupling gel is used to assure proper
coupling between the electrode and the patient and to help protect the
epidermis. As with other skin-tightening devices, the gentle heating induces
collagen denaturation, contraction, and subsequent synthesis. Repeat
treatments have been shown to improve the appearance of wrinkles and skin
laxity, but results are somewhat limited due to the discrete amount of energy
applied. Early protocols recommended 8-weekly treatments for best results,
but the treatment paradigm has since been revised to two treatments spaced
1 month apart, with some patients requiring an additional treatment.
Unipolar RF
Another form of delivery is unipolar in which there is one electrode, no
grounding pad, and a large field of RF emitted in an omnidirectional
field around the single electrode. This form is analogous to a radio tower
broadcasting signals in all directions.
The Accent (Alma Lasers, Inc, Ft Lauderdale, FL)

The Accent RF system is designed for continuous skin contact using two
handpieces: the unipolar to deliver RF energy to the subcutaneous adipose
tissue for volumetric heating and the bipolar to deliver RF energy to the
dermis for nonvolumetric heating.
It uses both unipolar and bipolar RF and delivers different depths of RF
current to the skin, theoretically bipolar for more superficial heating and
unipolar for deeper dermal heating. Several clinical trials describe its use in
reducing the appearance of cellulite and its effects on tissue tightening.
Multipolar Noncontact RF Device

Vanquish (BTL Aesthetics, Prague, Czech Republic)
Previously discussed RF devices are operator dependent. This device has
been designed for a contactless deep-tissue thermal-energy application. The
applicator-generator circuitry is engineered to selectively deliver the energy
to the tissue layer with specific impedance. This high-frequency system
focuses energy specifically into the adipose tissue, while limiting delivery to
the epidermis, dermis, and muscles. Animal studies have shown a 70% fat
reduction in the treated abdominal area. Proportionate results have been
seen in humans also.
Conclusion
There are certain important rules that determine results with RF:
1. Though the early results are marked, the late results are difficult to
judge objectively. This makes an excellent photographic documentation
essential. This is because delayed neocollagenesis and long-term woundhealing response is an important aspect of RF therapy and subjects may
have difficulty, accurately remembering the exact condition of their skin
pre-treatment, particularly when 6 or more months have passed.
2. Young patients respond best to therapy. This can be partly due to the
replacement of heat-labile collagen bonds by irreducible multivalent
cross-links as patients age, making older skin less susceptible to heatinduced tissue tightening.
Infrared light devices

1. Broadband infrared light in the range of 800 to 1,800 nm, has also been
utilized for nonablative tissue tightening. The first such light-based
system was the Titan (Cutera, Brisbane, CA). It utilizes light energy in
the range of 1,100 to 1,800 nm to target water as a chromophore, causing
collagen denaturation and ultimately collagen remodeling and tissue
tightening. Studies on this device have shown that minimal to excellent
results can be obtained with immediate skin tightening, but clinical
skin tightening does not always correlate with immediate positive
histological findings. This is explained by the fact that full clinical effect
may take weeks or months to be demonstrated owing to a secondary
wound healing response. (Ruiz-Esparza J, 2006 and Zelickson B). A
lower fluence range of 3040 J/cm2, 23 treatments, 12 passes, and extra
passes on areas that need immediate contraction or along vector lines
yielded best results.
2. The StarLux IR (Palomar Medical Technologies, Burlington, MA)
delivers fractionated energy through the handpiece of the device at a
wavelength range of 850 to 1,350 nm, which also targets water as the
principal chromophore. Multiple treatments are required for optimal
results.
3. The SkinTyte device (Sciton, Palo Alto, CA) utilizes light at a wavelength
range of 800 to 1,400 nm.
4. Other laser wavelengths that have been used for tissue tightening
include the 1,064 nm and 1,320 nm wavelengths. The chromophores for
the 1,064 nm wavelength, in decreasing order, are melanin, hemoglobin
and water, and the primary chromophore for the 1,320 nm wavelength is
water.
Though studies (Taylor and Prokopenko, 2005) have shown results better
than a monopolar radiofrequency system, some authors point out that
(Key, 2007) that the 1,064 nm improves the lower face, more than the
upper face. The mild improvemnet noted by Trelles (2001) using a 1,320
nm laser system shows that combining laser treatment with parallel
epidermal treatment may yield better results and achieve higher patient
satisfaction.
Ultrasound devices
High-intensity focused ultrasound (HIFU) is the most recent player to enter
the skin-tightening technology realm.
The basic concept being that the intense ultrasound field vibrates tissue
thus the consequent friction created between molecules causes them to
absorb mechanical energy and leading to secondary generation of heat.
Intense focused ultrasound for skin-tightening applications uses short,
millisecond pulses with a frequency in the megahertz (MHz) domain, rather
than kilohertz (kHz) as is used in traditional HIFU, to avoid cavitational
processes. Intense focused ultrasound also uses significantly lower energies
than traditional HIFU, 0.510 J versus 100 J, which allows thermal tissue
changes without gross necrosis.
The main advantage to focused ultrasound is the potential for greater
depth of skin changes than other technologies with the added benefit of
precisely controlled, focal tissue injury. Ultrasound energy is able to target
deeper structures in a select, to ocused fashion without secondary scatter and
absorption in the dermis and epidermis. The first intense focused ultrasound
device on the market is the Ulthera system Ulthera Inc., Mesa, AZ) and is
covered in detail in a following chapter.
Conclusion
Nonsurgical skin tightening is best suited for patients with mild-to-moderate
laxity. Thus, cases with laxity of the aponeurotic system are not candidates
for this therapy. Combination therapy is the ideal approach in most cases.
A suggested approach in a patient desirous of a brow lift and a jawline
definition may be a combination of botox to the orbicularis oculi and
platysma in addition to skin tightening. Fillers can be used in the mid face,
brow/temples and jawline.
The key to success is ideal patient selection and management of
expectations. As there remains a lack of an FDA-approved method for
measuring skin tightening, most of the results are based on before and after
photos. A few assessment scales are given in Table 8.3 and 8.4, which can help
the clinician objectively assess results. Large-scale randomized controlled
trials are still necessary to determine optimal treatment parameters for most
of the newer bipolar devices and USG.
Table 8.3 The Fitzpatrick Wrinkle Classication System

Class
Wrinkling
Score
Degree of elastosis
Fine wrinkles
13
Mild (ne textural changes with

subtly accentuated skin lines)
II
1.Fine-to-moderate depth
wrinkles
2. Moderate number of lines
46
Moderate (distinct popular elastosis

[individual papules with yellow
translucency under direct lighting]
and dyschromia)
III
1. Fine-to-deep Wrinkles
2. Numerous lines
3. With or without redundant
skin folds
79
Severe (multipapular and conuent

elastosis [thickened yellow and
pallid] approaching or consistent
with cutis rhomboidalis)
Table 8.4 The Leal Laxity Classication System

Laxity
Description
Supercial laxity limited to the skin
Structural laxity involving

subcutaneous tissue
AB
Combined supercial and structural

laxity
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Clinical evaluation of non-ablative radiofrequency facial rejuvenation. J Cosmet
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2. Alster TS, Tanzi E. Improvement of neck and cheek laxity with a non-ablative
radiofrequency device; a lifting experience. Dermatol Surg. 2004;30:503-7.
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4. Biesman BS, Baker SS, Carruthers J, Leal Silva H, Holloman EL. Monopolar
radiofrequency treatment of human eyelids: A prospective, multicenter, efficacy
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6. Doshi SN, Alster TS. Combination radiofrequency and diode laser for
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7. Dover JS, Zelickson B and the 14-Physician multispecialty consensus panel:
Results of a survey of 5,700 patient monopolar radiofrequency facial skin
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8. Fitzpatrick RE, Geronemus RG, Goldberg DJ, Kaminer MS, Kilmer SL, RuizEsparza J. Multicenter study of non-invasive radiofrequency for periorbital tissue
tightening. Lasers Surg Med. In press
9. Friedman DJ, Gilead LT. The use of hybrid radiofrequency device for the treatment
of rhytides and lax skin. Dermatol Surg. 2007;33(5):543-51.
10. Gold MH. Update on tissue tightening. Journal of Clinical and Aesthetic.
Dermatology. 2010;3:36-41.
11. Key DJ. Single-treatment skin tightening by RF and long-pulsed, 1064-nm Nd :
YAG laser compared. Lasers in Surgery and Medicine. 2007;2:16-75.
12. Lolis MS, Goldberg DJ. Radiofrequency in cosmetic dermatology: a review.
Dermatol Surg. 2012;38(11):1765-76.
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2003;2:495-500.
14. Ruiz-Esparza J, Gomez JB. Nonablative radiofrequency for active acne vulgaris:
the use of deep dermal heat in the treatment of moderate to severe active acne
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15. Ruiz-Esparza J, Gomez JB. The medical facelift: a non-invasive, non-surgical
approach to tissue tightening in facial skin using non-ablative radiofrequency.
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by low-fluence irradiation with new infrared device: a report of 25 patients.
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17. Taylor MB, Prokopenko I Split-face comparison of RF versus long-pulse Nd:YAG
treatment of facial laxity. Journal of Cosmetic and Laser Therapy. 2006;8:17-12.

18. Trelles MA, Allones I, Luna R. Facial rejuvenation with a nonablative 1320-nm
Nd:YAG laser: a preliminary clinical and histologic evaluation. Dermatologic
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modification of collagen. J Shoulder Elbow Surg. 1993;8:339-44.
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on forehead and abdominal skin. Dermatologic Surgery. 2006;32:897-901.
CHAPTER
Aesthetic Intense Focused Ultrasound

(IFUS): Clinical Perspective on
Fitzpatrick Skin Types IIIVI
Shahin S Nooreyezdan, Inder Raj S Makin
INTRODUCTION
During the past few decades, surgical intervention has been the mainstay
for managing skin laxity of the face and neck as well as attaining a favorable
contoured proportion of the abdomen and torso. There is a greater awareness
for aesthetic maintenance and demand for attaining a more proportionate
and youthful appearance among various societies worldwide, based on an
increasing life expectancy, socioeconomic status, and persistent media
coverage on the need for favorable aesthetic and cosmetic outcomes. This
need for reducing tissue laxity on the face, neck and other exposed body
skin surfaces as well as a proportionally contoured body exists in all ethnic
groups. A growing portion of the target population is averse to direct surgical
interventions and related greater risk and downtime, hence, more patients
opt for undergoing minimally- or non-invasive procedures. Prospective cases
are willing to adopt techniques that require repeat visits, and accept clinical
outcomes that are more modest as compared to the surgical procedures.
Non-invasive or minimally-invasive aesthetic interventions most often
are performed by energy-based systems, such as laser or other photonbased techniques, radiofrequency (RF) current-based devices, or intense
focused ultrasound (IFUS) based modalities. Each of these techniques is
capable of attaining a certain range of skin and superficial tissue response,
and by extension clinical effect, based on biophysical characteristics of the
specific energy modality. Attaining a successful clinical outcome to mitigate
a particular clinical presentation is dependent on matching the right energy
source to the tissue.
This chapter will discuss the role of IFUS systems that are presently
deployed in the management of dermatologic and aesthetic presentations.
The organization of this chapter is as follows in Box 9.1.
PHYSICS AND INSTRUMENTATION

Ultrasound is a form of mechanical energy, which propagates from the source
outwards through any medium, such as water, tissue, or air, as a wave. This

Box 9.1
Summary points of IFUS
Description of the physical concept for focused ultrasound beams, relevant biophysics, and
instrumentation
Clinical application of IFUS for aesthetic and plastic surgery application, and related tissue
effects
Clinical results following use of IFUS, with emphasis on treatment of cases with skin of
color (Fitzpatrick skin types IIIVI)
Summary and conclusion
propagation is similar to the rippling of peaks and troughs one observes

when a stone is dropped in a quiescent pond. Ultrasound (when sound is
operating at greater than 20,000 cycles per second), has the characteristics
of its wavelength, intensity, scattering, and absorption leading to localized
heating or dispersive changes in the medium, due to frictional and relaxational
molecular phenomena. Similar to photon energy, ultrasound energy has an
inverse relationship between frequency and wavelength. For example, at
frequencies of interest (110 MHz), in the present context of the discussion,
the wavelength of the propagating energy in tissue can vary from 1.5 0.15 mm.
For human tissue applications, ultrasound energy can therefore, be directed
or focused to a very small spatial zone, as shown in Figure 9.1 (ter Haar, Miller
et al.). For dermatologic and aesthetic applications, this ultrasound energy
concentration can be attained up to several millimeters in the body. This
characteristic of focused ultrasound is unique compared to lasers and other
photon-based energy modalities, which scatter very rapidly within the first
millimeter of skin and dermal tissue. Further, in the radiofrequency-based
(RF) energy sources, which are widespread in aesthetic applications, the
energy modality is diffused due to the long (several centimeters to meters)
wavelength, hence cannot be focused in the body. Due to the primary
physics of the modality, RF energy dissipates within tissue from the source
plane outwards, being maximum at-source, decaying rapidly as it progresses
deep in the tissue.
The aesthetic practitioner is familiar with ultrasound devices in practice,
however, mainly as minimally invasive devices for ultrasound-assisted
liposuction (UAL) or diathermy-like external ultrasound-assisted liposuction
(EXT) (Rohrich RJ et al.) The UAL devices operate at kilohertz (kHz) energy
levels are minimally invasive, relying on local tissue effects. The EXT systems
operate at about 13 MHz, radiating continuously with an unfocused
geometry, at relatively low ultrasound intensities (0.53 W/cm2). The highly
focused systems described in the present section are distinct from the UAL
and EXT devices.
Focused ultrasound devices operating at MHz frequency that are capable
of selectively coagulating tissue or non-thermally damaging tissue have been
used consistently over the past decades for various clinical applications.
Several extensive reviews have been published, (ter Haar GT, Miller DL et
IFUS: Clinical Perspective on Fitzpatrick Skin Types IIIVI 321
Fig. 9.1: Schematic represantaion of a generalized focused beam for aesthetic

applications. The focal spot can concentrate energy 120 mm deep from the skin
surface
al, Kennedy JE et al, ter Haar GT, Coussios C), however, most of the focused
ultrasound devices aim to debulk the tissue in the target organ. The first
reported application for non-invasive aesthetic procedures were developed
in the past 1012 years. Based on the precise procedures developed, i.e.,
lipolysis, or skin tightening applications, the technologies implemented
varied.
Non-invasive body contouring or lipoplasty using ultrasound was the initial
goal and laid the foundations for two devices, the Liposonix and Ultrashape
systems, respectively. The goal of each of these concepts was to coagulate or
irreversibly damage subcutaneous fat tissue in the abdominal region, flanks,
and thigh regions, at 1020 mm depth. Further, the delivery of energy from
these focused high power ultrasound sources is intended to blanket the
band of tissue around the 1015 mm depth, such that a substantive (50500cc)
of tissue was lysed with ultrasound energy. Both these requirements, can be
fulfilled by large dimensioned (25 mm and above) ultrasound transducer
sources, with high outputs (order of 100 W acoustic power), which operate
between 0.52.5 MHz. Technical details and configuration for the Liposonix
and Ultrashape systems have been described in the scientific literature
extensively (Jewell and Desilets CS, Fatemi A, Brown SA et al., Teitelbaum
S et al., Coleman KM et al.). One key difference between the Liposonix and
Ultrashape techniques is that the focused field from Liposonix source is at
approximately 2 MHz frequency, which thermally coagulates the tissue at the
focal zone as energy is selectively absorbed in that region. The Ultrashape
design generated focused ultrasound energy at less than 1 MHz (~0.25 MHz),
and multiple short pulses much shorter than 1 second (milliseconds). At this
low frequency and pulsing regime, it is claimed that the focal tissue lyses
results primarily from non-thermal mechanisms, such as rapidly growing and
collapsing bubbles (cavitational) phenomena (Brown et al.). Both devices
have since been used in the clinic worldwide on an experimental and routine
basis, whereas Liposonix has received FDA approval for non-invasive waist
circumference reduction.
In the treatment of skin laxity by tightening and lifting dermal and
subdermal skin tissue on the face, neck and upper body, a different, more
selective approach is used in the Ultherapy procedure. Ultherapy has been
approved to lift skin above the eyebrow, on the neck and under the chin. In
contrast to an approach for attaining tissue lysis through heat or cavitational
mechanisms, the highly focused transducer configurations with Ultherapy
create a line of discrete thermal coagulation points (TCP) at a predefined
depth. These zones of thermal coagulation are interspersed by adequate
normal unexposed tissue. The Ulthera system handpiece can accommodate
a series of limited use transducers which enable the user to deliver microfocused ultrasound energy at various depths, such as 4.5, 3.0, or 1.5 mm.
Based on the depth of operation, TCP size, and treatment safety, each probe
is configured to operate at specific frequencies (4, 7, or 10 MHz). The nominal
size of each TCP is on the order of 1 mm3 or less, hence the terminology
microfocused. The Figure 9.2 shows the actual beam measured for a 4
MHz MFU transducer (Fig. 9.2A). The panel (Fig. 9.2B) is the corresponding
numerically simulated thermal coagulation zone, while the actual thermal
zone achieved at ~4 mm depth in porcine skin tissue in vivo is shown in (Fig.
9.2C). These results provide a good comparison between instrumentation
testing, numerical prediction and preclinical studies. The Ulthera concept for
microfocused ultrasound is shown in Figure 9.3, whereby TCPs at 4.5 and 3
mm depths in porcine tissue are attained. An additional functional feature of
the Ulthera system is the integrated quasi-realtime ultrasound imaging for
the clinician as the energy is being delivered in skin tissue. The integrated
imaging capability combined with highly-focused therapeutic ultrasound has
been coined as Microfocused Ultrasound-Visualization (MFU-V), with FDAclearance to visualize dermal and subdermal tissue. Details and specifics of
instrumentation design and validation have been reported in the literature
(Laubach HJ, White WM, Gliklich RE, Alam M).
The aesthetic clinician is being offered an ever-increasing list of energybased technologies, promising to provide non-invasive aesthetic solutions
for skin and subcutaneous tissue. The probability of an appropriate match
of energy source to a particular aesthetic application is based on the user
attaining an understanding of energy-tissue interaction of various energy
modalities. The Figure 9.4 shows a schematic of physically realistic energy
profile of three energy modalities, laser RF and microfocused ultrasound
following exposure to skin tissue. If the goal is to attain coagulative tissue
Figs 9.2A to C: (A) Excellent comparison of microfocused beam spot; (B), The
numerically predicted thermal damage zone; (C) The actual achieved porcine tissue
coagulation, under gross-sectioning (vital staining). The single focal spot is a fraction
of a rice grain in dimensions (With permission from Ulthera, Inc., USA)
Figs 9.3A and B: Gross-section (vital stain) of porcine tissue exposed with 4.5 mm and
3 mm depth transducers. Thermal coagulation zones can be placed at predetermined
planes below skin surface, while maintaining adequate intervening healthy tissue
(With permission from Ulthera, Inc., USA)
changes superficially (sub-millimeter depth), then laser energy is possibly

the most appropriate modality. Radiofrequency energy systems provide a
relatively diffused and progressively decreasing energy density profile, and
is possibly most appropriate to attain a generalized heating of skin tissue.
An RF source can achieve tissue coagulation only in selected zones, when
these zones of high impedance to RF energy are coincidently in the path of
high electrical impedance for the field, not necessarily controllable by the
Fig. 9.4: Schematic representation of laser, RF, and MFU biophysical capabilities to
attain tissue coagulation in skin tissue. The physically realistic temperature profiles
are mapped over therapeutically relevant skin layers (With permission from Ulthera,
Inc., USA)
operator. By selecting specific probe types, the microfocused systems enable

attaining precise and predictable TCPs at specified depth planes, based on
the operators clinical requirements. Eventually each energy modality has its
merits and limitations, however, an understanding of physical characteristics
of a particular energy sources maximizes the possibility to deliver optimal
clinical treatment (Dobke MK et al.).
TISSUE EFFECT AND CLINICAL APPLICATION

The goal of non-invasive focused ultrasound treatments, whether for body
contouring or for skin tightening and tissue lifting is to concentrate energy at
the plane of clinical interest while sparing the skin surface and intervening
tissue. The Liposonix device is applied to abdominal skin and flanks for
patients with mild to moderate subcutaneous fat deposition such that about
2.5 cm of adipose tissue can be measured using a pinch-test. The abdomen
and the flanks are divided into nine regions 2.5 2.5 cm in dimensions, and
13 passes of exposures totaling 109271 J/cm2 were delivered using a 2 MHz
focused applicator, such that a band of subcutaneous region 1020 mm
below the skin surface is targeted. Tissue thermal coagulation results at the
aspect ratio of the ellipsoidal profile of the focal zone of the 2 MHz transducer
(see Fig. 9.1), whereby these zones are longitudinally stacked next to each
other to create a circumferential band of thermally necrosed adipose tissue
along the patients girth. Details of the tissue effect with acute gross pathology
and histology are described by Jewell, Desiletz, Gadsden EI and Fatemi et al.
Clinical results following Liposonix HIFU procedures for body contouring
have been reported in multicenter human subject studies (Fatemi et al.,
Jewell et al., 2011). Clinical endpoints in these studies, showed a measurable

reduction in girth, controlled photographic evidence of body contour
improvement and a subjective patient satisfaction, assessment of treatment
outcome. Side effects and complications were documented for the test cases.
Photographic and quantitative assessments were recorded at 4, 8, and 12
weeks post-procedure.
Body-contouring procedures using Liposonix technique has evolved
over the past years. The target patient population is one having mild to
moderate subcutaneous adipose tissue accumulation, and one averse to any
invasive procedures. The current protocols are evolving towards 13 treatment
sessions at much lower energy density levels (~45 J/cm2), compared to the
settings from initial studies. Pain, bruising, edema, and paresthsias as well as
only subtle outcomes are existing issues with the technology.
ULTHERA
Achieving skin tissue tightening and lifting of sagging tissue has been
accomplished successfully by implementing the Ultherapy MFU technique
under integrated quasi-continuous ultrasound visualization. This approach
was initially demonstrated in controlled clinical studies, to be safe and
efficacious in treating the face and upper neck, while lifting the eyebrow height
in >80% cases (reviewer masked) (Gliklich RE and Alam et al.) The multiple
TCPs with intervening normal subcutaneous tissue result in the selective
tissue necrosis followed by acute tissue shrinkage and regeneration of new
collagen. Ultherapy procedure is approved by US-FDA for the indications:
improvement of eyebrow height, and non-invasively lift lax tissue on the neck
and the submental region.
The present treatment guidelines for the face and upper neck consist
of the use of a family of four transducers: 4 MHz, 4.5 mm; 7 MHz, 3.0 mm;
7 MHz, 4.5 mm; and 7 MHz, 3.0 mm (narrow). These transducers enable the
clinician to place a series of up to 800 lines per a manufacturer recommended
protocol, in two planes4.5 mm and 3.0 mm depth. Depending on the
transducer selected, each line consists of 1522 TCPs, which are places at the
specified depth subcutaneously.
The probes are depicted in Figure 9.5. The user interface is intuitive, and
the clinician is guided through selection of treatment region as well as number
of lines of treatment with a specified transducer in that region. Through
interchangeable transducers, the same system can be used for thermally
coagulating focal zones at selected depths in the tissue, under simultaneous
imaging monitoring.
Patient comfort and minimizing intraprocedural pain are the key bases for
safety with the Ultherapy procedure. The initial treatment guidelines for face
and neck was a placement of up to 500 lines, with 4 MHz, 4.5 mm and 7 MHz,
3.0 mm defaulting at 1.2 J, and 0.45 J energy respectively 5+ guidelines).The
Figs 9.5A and B: (A) The interactive touchscreen user interface; (B) Photograph of the
Ulthera system and transducers (With permission from Ulthera, Inc., USA)
present guidelines recommend the delivery of 800 lines on the face and neck,
with 0.9 J (4 MHz, 4.5 mm) and 0.3 J (7 MHz, 3.0 mm), respectively. Patient
outcomes were comparable for the two treatment regimens, while the pain
scores recorded were lower by an average of 1.5 points on a 10 point pain
scale (statistically significant) (Ulthera white paper). The Figure 9.6 illustrates
the treatment plan with the current Amplify guidelines from Ulthera to
adequately treat the face and upper neck. The depth of TCP placement in the
pre-auricular, and mid-face region can reach the level of superficial musculoaponeurotic system (SMAS), thereby capable of robust tissue shrinkage and
lifting (White, Gliklich, Day, Dobke, MacGregor, Har-Shai Y).
There is no need for a local anesthetic, since the delivery of energy is deep
in the subcutaneous region (Alam et al). As a firstline of intraoperative pain
management, a loading dose of up to 800 mg Ibuprofen, 60 90 minutes prior
to the Ultherapy procedure should be adequate, however, this regimen can
be modified on a patient-to-patient basis (MacGregor et al).
Prior to procedure, a detailed case assessment is recommended, as well as
a consult to understand and establish the patients expectations. Standardized
photographs of the case before, immediately after and at 60 and 90 days is
highly recommended, in order to, (1) obtain a record of the pre- and postprocedure changes of the face and neck region, (2) establish the presence or
absence of any procedure related complications. Some representative preand post-Ultherapy procedure results at 90, 120, and 360 days are shown in
Figures 9.7 and 9.8.
Figs 9.6A and B: Treatment guidelines (Amplify) for Ultherapy procedure. Up to

800 lines, with 12,000 TCPs are delivered using the 4.5 and 3.0 transducers at two
planes of the skin tissue (4.5 mm and 3.0 mm) (With permission from Ulthera, Inc.,
USA)
Microfocused ultrasound is an energy-based system, and its prudent and

controlled use is the key to minimize procedural complications and adverse
events. Following established guidelines is important, especially avoiding
regions of significant nerve distributions, described as no-fly zones in
the guidelines (Figure 9.6). Known side-effects during procedure are pain,
discomfort, and transient edema. Some linear cutaneous striations and
rare dysthesia can occur post-procedurally, which resolves over 14 weeks.
Detailed description of safety and side-effects are discussed in papers by
MacGregor et al., Sasaki GH et al., and Dobke MK et al.
Fig. 9.7: Full-face and neck treatment with sustained improvement of eyebrow height,
nasolabial folds, jawline and lifting of neck tissue over 360 days. (With permission from
Ulthera, Inc., USA)
Figs 9.8A and B: Results at 120 Days post treatment, with substantial improvement
in mid, lower face, jawline definition and neck laxity (A) Female; (B) Male (With
permission from Ulthera, Inc., USA)
Recent guidelines and reports related to use of Ultherapy for full neck,
dcolletage, arms, abdomen and thigh region have been published. (Sasaki
et al and Alster et al)
PATIENTS OF COLOR (FITZPATRICK SKIN TYPES IIIVI)

The ideal implementation and broad dissemination of energy-based systems
for non-invasive surgical procedures should be predicated on a colorblind treatment approach. This goal is further relevant since more than 75
percent of the worlds population is of pigmented skin types IIIVI (Halder
RM). Despite these ethnic statistics, the safe use of energy-based systems
in skin of color is not always possible, due to the biophysical limitations of
particular energy modalities. For example, the use of photon-based devices
(superficial depth and chromophore sensitive) is non-optimal for skin of
color in aesthetic procedures, due to the possible adverse effects, such as
hyper-pigmentation and other discromias, scarring and keloid formation.
Compared to lighter Fitzpatrick skin types, the darker skin types are known
to have unique characteristics, such as a thick compact dermis, abundance of
melanin, preservation of skin elasticity (Halder RM, Rawlings AV, Davis EC).
Not all energy modalities can fulfill the requirements to adequately and safely
treat the darker skin types.
The unique requirements for effective treatment are: (a) non-invasive
inside-out approach, (b) chromophore insensitivity and, (c) ability to
access multiple deeper layers (dermis and SMAS). Microfocused ultrasound
systems are particularly suited to meet these requirements, since the energy
for focal thermal coagulation bypasses the melanocytes, and is insensitive
to other chromophores in the skin tissue. The energy is deposited depthselectable, and order of millimeters into the dermis and subcutaneous tissue.
The use of Ultherapy in SE-Asia has been reported in the literature (Suh DH,
Chan NP). One presentation describing the use of Ultherapy in patients of
color has been made at a plastic surgery conference (Harris MO). However,
no formal study of Asian-Indian skin type treatment with Ulthera has been
reported to-date.
A systematic case series was conducted in New Delhi, India to investigate
the safety and efficacy of Ulthera procedures on face and upper neck
treatment in Asian-Indian skin types (Nooreyezdan SS). The included cases
in the study had the following characteristics:
Females = 32; Males = 6
Age: 4270 Years; Average = 49.8 Years
Skin Types: Fitzpatrick Skin Types IIIVI
No history of cosmetic procedures 6 months prior to Ulthera procedure
Willingness to not undergo and cosmetic procedures for at least 6
months post-Ultherapy
Photographic and clinical assessment was performed immediately

following Ultherapy
Follow-up standardized photographs, frontal view (45 and 90) taken at
day 28, 60, 90 and 180.
The study was conducted by four investigators; three plastic-reconstructive
surgeons, and one dermatologist, based in India. After the initial training
with Ulthera instrumentation, the investigators performed the procedures on
their own recruited cases. All procedures were performed over 10 days at the
same clinical location, using the same equipment. An identical protocol was
followed by all clinicians. The steps for processing a case are as below:
Provide two Combiflam (Ibuprofen 400 mg, paracetamol 325 mg), to
patient, 6090 minutes prior to Ulthera procedurepain mitigation
Consult patient and obtain patients consent
Obtain standardized preprocedure photographs
Mark face and neck region per treatment plan
Deliver Ulthera procedure per Ulthera Protocol 5-PLUS (up to 500
Ultherapy treatment lines)
Record patient pain scores (VAS 010), and other responses
Conduct evaluation at half-procedure point
Post-procedure assessment and standardized photography
Day-60 follow-up standardized photography
Day-90 follow-up photography
Day 180 follow-up photography (subset of cases)
The Ultherapy procedure was well-tolerated by all 38 cases, although
pain score could not always be recorded. All cases could resume their
daily activity following Ultherapy without any additional precautions or
downtime. At day 60, 36 out of 38 cases returned for follow-up visit. For day
90 follow-up, 27 subjects returned for photography and assessment, while 14
subjects returned for a follow-up photography and assessment on day 180.
In this, first reported comprehensive case-study for patients of Asian-Indian
skin types, Ulthera procedure could be safely delivered to all the enrolled
patients. The cases had no acute or long-term sequelae.
Greater than 65% cases demonstrated a clinician evaluated mild to
moderate improvement in the standardized photographic assessment.
Selected photographs from the case study showing an increase in the eyebrow
arch, mid-face tightening, improved jawline definition, improved submental
tissue laxity, nasolabial fold improvement, and greater ovaling of the lower
face are shown in Figures 9.9 to 9.12. Following this study, greater than 100
cases have since been clinically treated with favorable results and no adverse
events by one of the investigators based in India.
CONCLUSION
This chapter describes the role of intense focused ultrasound (IFUS)
technology in non-invasive aesthetic applications for tissue laxity
Figs 9.9A and B: (A) Eyebrow elevation at 90 days; (B) Lower face ovaling, improved
nasolabial folds at 60 days
Fig. 9.10: Tissue tightening mid-cheek, improved jawline, submental region and
angle of neck at day 90
management and body contouring. The distinction of IFUS from ultrasoundassisted liposuction (UAL) has been made, as well as the basic biophysical
principles which are characteristic of IFUS. The characteristics of various
IFUS clinical systems such as Liposonix, Ultrashape, and Ulthera, have
been explained, as well as their therapeutic role in non-invasive cosmetic
procedures. Differentiation between principal energy modalities has been
Figs 9.11A and B: Global tissue tighteningeyebrow height improvement, improved

nasolabial folds, jawline definition, submental tightening and angle of neck at day 90
Figs 9.12A and B: (A) Improved jawline definition, tightening of submental area, no
post-treatment sequelae in darker skin type; (B) Day 180 post-treatment: Consistent
mid-face and submental tissue tightening
explained, as well as how their characteristics fit in attaining known tissue

effects during clinical procedures. Details about the Ulthera technology
and procedures have been expanded. Emphasis has been made in a first
time reporting of a 38-patient case study describing the use of Ultherapy
on Asian-Indian skin types. Photographic examples of pre-and post-results
illustrate the outcomes from Ulthera procedures. Key issues with energy
modalities for treatment of skin of color have been listed, in the context of the
unique suitability of microfocused ultrasound (MFU-V) for treatment of dark
skin types laxity and tissue tightening. The current published information for
IFUS technologies has been listed in a comprehensive bibliography.
BIBLIOGRAPHY
1. Alam M, White LE, Martin N, et al. Ultrasound tightening of facial and neck
skin: A rater-blinded prospective cohort study. J Am Acad Derma-Dermatol.
2010;62:262-9.
2. Alster TS, Tanzi EL. Noninvasive lifting of arm, thigh, and knee skin with
transcutaneous intense focused ultrasound. Dermatol Surg. 2012;38:754-9.
3. Brown SA, Greenbaum L, Shtukmaster S, Zadok Y, Ben-Ezra S, Kushkuley L.
Characterization of nonthermal focused ultrasound for noninvasive selective fat
cell disruption (lysis): technical and preclinical assessment. Plast Reconstr Surg.
2009;124(1):92-101
4. Chan NP, Shek SY, Yu CS, Ho SG, Yeung CK, Chan HH. Safety study of
transcutaneous focused ultrasound for non-invasive skin tightening in Asians.
5. Coleman KM, Coleman WP 3rd, Benchetrit A. Non-invasive, external ultrasonic
lipolysis. Semin Cutan Med Surg. 2009;28(4):263-7.
6. Davis EC, Callender VD. Postinflammatory hyperpigmentation: a review of the
epidemiology, clinical features, and treatment options in skin of color. J Clin
Aesthet Dermatol. 2010;3(7):20-31.
7. Dobke MK, Hitchcock T, Misell L, Sasaki GH. Tissue restructuring by energybased surgical tools. Clin Plast Surg. 2012;39:399-408.
8. Doris D. Micro-Focused Ultrasound for Facial Rejuvenation: Current
Perspectives. Research and Reports in Focused Ultrasound. 2014 (in print)
9. Fatemi A. High-Intensity Focused Ultrasound Effectively Reduces Adipose
Tissue. Semin Cutan Med Surg. 2009;28:257-62.
10. Gadsden EI, Aguilar MT, Smoller BR, Jewell ML. Evaluation of a novel highintensity focused ultrasound device for ablating subcutaneous adipose tissue for
noninvasive body contouring: safety studies in human volunteers. Aesthet Surg
J. 2011;31(4):401-10.
11. Ghassemi A, Prescher A, Riediger D, Axer H. Anatomy of the SMAS revisited.
Aesthetic Plastic Surgery. 2003;27:258-64.
12. Gliklich RE, White WM, Slayton MH, et al. Clinical pilot study of intense
ultrasound therapy to deep dermal facial skin and subcutaneous tissues. Arch
Facial Plast Surg. 2007;9:88-95.

13. Halder RM, Ed. Dermatology and Therapy of pigmented skins. Taylor and
Francis, Boca Raton, 2006
14. Harris MO. Evaluation of Micro-Focused Ultrasound for Obtaining Lift and
Tightening of the Cheek Tissue and Improvement in Jawline Definition and
Submental Skin Laxity in Patients with Fitzpatrick Skin Phototypes 3 through 6.
AAFPRS Washington DC, Sept. 2012
15. Har-Shai Y, Bodner SR, Egozy-Golan D, et al. Mechanical properties and
microstructure of the superficial musculoaponeurotic system. Plast Reconstr
Surg. 1996;98:59-70.
16. Jewell ML, Baxter RA, Cox SE, Donofrio LM, Dover JS, Glogau RG, et al.
Randomized sham-controlled trial to evaluate the safety and effectiveness of a
high-intensity focused ultrasound device for noninvasive body sculpting. Plast
Reconstr Surg. 2011;128(1):253-62.
17. Jewell ML, Desilets C, Smoller BR. Evaluation of a Novel High-Intensity Focused
Ultrasound Device : Preclinical Studies in a Porcine Model. Aesthetic Surgery
Journal. 2011;31:429
18. Jewell ML, Solish NJ, Desilets CS. Noninvasive body sculpting technologies
with an emphasis on high-intensity focused ultrasound. Aesthetic Plast Surg.
2011;35(5):901-12.
19. Kennedy JE, ter Haar GR, Cranston D. High intensity focused ultrasound:
Surgery of the future? Br J Radiol. 2003;76:590-9.
20. Laubach HJ, Makin IR, Barthe PG, et al. Intense focused ultrasound: Evaluation
of a new treatment modality for precise microcoagulation within the skin.
21. MacGregor JL, Tanzi EL. Microfocused ultrasound for skin tightening. Semin
Cutan Med Surg. 2013;32:18-25.
22. Miller DL, Smith NB,, Bailey MR, Czarnota GL, Hynynen K, Makin IRS,. Overview
of Therapeutic Ultrasound Applications and Safety Considerations. Ultrasound
Med. 2012;31:623-34.
23. Nooreyezdan SS. Face and Neck Tissue Lifting and Tightening with MicroFocused Ultrasound in Fitzpatrick Skin Types II VI. ISAPS, Goa, Jan. 2012
24. Rawlings AV. Ethnic skin types: are there differences in skin structure and
function? International Journal of Cosmetic Science, 2006;28:79-93.
25. Rohrich RJ, Morales DE, Krueger JE, Ansari M, Ochoa O, Jack Robinson, et. al.
Comparative Lipoplasty Analysis of in Vivo-Treated Adipose Tissue. Plastic and
reconstructive surgery. 2000;105(6):2152.
26. Sasaki GH, Tevez A. Clinical efficacy and safety of focused-image ultrasonography:
A 2-year experience. Aesthet Surg J. 2012;32:601-12.
27. Sasaki GH, Tevez A. Microfocused Ultrasound for Nonablative Skin and
Subdermal Tightening to the Periorbitum and Body Sites: Preliminary Report
on Eighty-Two Patients. Journal of Cosmetics, Dermatological Sciences and
Applications. 2012;2:108-16.
28. Suh DH, Shin MK, Lee SJ, et al. Intense focused ultrasound tightening in Asian
skin: Clinical and pathologic results. Dermatol Surg. 2011;37:1595-1602.
29. Teitelbaum SAI, Burns JL, Kubota J, Matsuda H, Otto MJ, Shirakabe Y, et al.
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ter Haar G. Acoustic Surgery, Physics Today 29-34,2001
ter Haar GT, Coussios C. High intensity focused ultrasound: physical principles
and devices. Int J Hyperthermia. 2007;23:89-104.
Ulthera Update White Paper. Comfort Management. 2012
White WM, Makin IR, Barthe PG, et al. Selective creation of thermal injury
zones in the superficial musculoaponeurotic system using intense ultrasound
therapy: A new target for noninvasive facial rejuvenation. Arch Facial Plast Surg.
2007;9:22-9.
White WM, Makin IR, Slayton MH, et al. Selective transcutaneous delivery of
energy to porcine soft tissues using intense ultrasound (IUS). Lasers Surg Med.
2008;40:67-75.
Chapter
10
Noninvasive Body Contouring

Vivek Nair, Kabir Sardana
Introduction
Noninvasive body contouring is an ever-expanding field that has seen
exciting research and development over the last decade. Beginning with
suction-massage machines over 20 years ago, the technology has progressed
to involve sophisticated laser and radiofrequency devices. The commonly
practiced laser lipolysis, is one component of the array of devices.
As per the revised nomenclature (Alam et al. 2013) the devices for Body
Contouring can be divided into three categories (Box 10.1).
This classification may seem daunting for someone getting into body
shaping platforms. However, the picture becomes clearer if the machines
are classified according to the energy used for transepidermal delivery to
Box 10.1 Body contouring devices (as per revised nomenclature by Alam et al.
2013)
A. Nonsurgical body contouring and fat reduction
1. Ultrasound

a. High intensity (e.g. Liposonix, Ultrashape)

b. Low intensity

c. Focused

d. Nonfocused (e.g. Bella contour)
2. Cryolipolysis (e.g. Zeltiq)
3. Low-intensity light therapy light (LLLT) (e.g. Zerona)
4. Massage
5. Electric eld (e.g. Bella contour)
B. Energy-device-assisted liposuction
1. Laser lipolysis with liposuction (e.g. CoolLipo, ProLipo, SmartLipo, LipoLite)
2. Ultrasound-assisted liposuction
3. Water-assisted liposuction (e.g. Body-Jet)
4. Power-assisted liposuction (e.g. MicroAire)
categories of: microwave thermolysis
1. Noninvasive
2. Invasive
Contd...
Noninvasive Body Contouring 337
Contd...
C. Radiofrequency and ultrasound skin tightening
1. Noninvasive radiofrequency

a. Monopolar radiofrequency (e.g. Thermage, Exilis)

b. Unipolar radiofrequency

c. Bipolar radiofrequency (e.g. Alma Accent, Syneron eMax)

d. Tripolar radiofrequency (e.g. Pollogen RegenXL)

e. Multipolar radiofrequency.
2. Minimally invasive radiofrequency
Needle insertion array
3. Fractional radiofrequency (by any radiofrequency delivery method listed above)
4. Focused, high-intensity ultrasound (synonym: ultrasound skin tightening) (e.g. Ulthera
Ultherapy).
the adipocyte; in which case there are four primary modalitiessuction/

massage machines, radiofrequency machines, ultrasound machines, and
laser machines.
The areas of fat deposition are essentially localized to certain areas (e.g.
love handles, lower abdomen bulges, thighs). Tumescent liposuction using
suction cannulas is a time-tested technique with about 300,000400,000
procedures performed in the US annually. Though overall a safe procedure
complications like prolonged swelling, areas of numbness, bruising, persistent
erythema, thrombophlebitis, and pulmonary embolism can occur. Given the
fact that many patients do not want to undergo surgery of any kind to remove
excess fat, the market for the noninvasive devices is expected to grow at an
exponential rate. In 2009, the projected figure for the body shaping platform
market was over $300 billion with over 9 million procedures performed world
wide. USA, Europe, and Southeast Asia have seen the maximum number of
these procedures, but the market in India is expected to follow a similar trend.
Excess fat and obesity are an epidemic wherein excess, but structurally
normal, adipose tissue is deposited. Cellulite, on the other hand, is best
considered a hormonally based structural phenomenon of adipose tissue. It
is seen almost ubiquitously in post-pubescent females and, rarely, in men. As
a result of these differences, the techniques and technology that effectively
treat excess fat may not have any effect on the appearance of cellulite, and
vice versa.
This chapter mainly deal with the noninvasive body contouring
technologies as well as a brief discussion on the minimally invasive lipo
suction techniques that have become possible, because of the use of lasers
and adjunctive technologies like radiofrequency and ultrasound.
Cellulite
This condition is characterized by a orange-peel appearance and is
localized to certain areas . Obesity, on the other hand is characterized by an
universal increase in size and number of adipose cells. Fat is a healthy tissue,
found in the human body that develops in terms of number of cells from birth
until full sexual maturity. Throughout the rest of our lives, the number does
not change, but the volume does. Adipose tissue in men is different from the
one in women:
numerically, men have 1718 million cells and women 2122 million
structurally, the connective tissue that surrounds the adipose cells
in men forms a mesh structure; in women, it is connected by fibers
positioned perpendicular to the tissue levels (Fig. 10.1).
Structurally, the subcutaneous compartment is different in patients with
and without cellulite. Based on analysis of adipose tissue, Nurnberger and
Muller reported indentations into the deep adipose tissue through the dermis
and perpendicular brous septae in women. In contrast, the brous septae
run in a crisscross pattern in men. Thus, the horizontal, crisscross pattern of
connective tissue at the dermalsubcutaneous junction and thicker dermis
prevents bulging or dimpling of fat in men (Fig. 10.1). Subcutaneous adipose
tissue is thicker with larger adipocyte lobules in skin with cellulite compared
with unaffected skin.
The factors that trigger the degenerative process of cellulite are lifestyle,
hormones, stress, clothing, genetic predisposition, physical disorders,
metabolic disorders, smoking, increased mass, age, medicines (contraceptive
pill, antidepressants), lack of physical exercise, etc.
The effect of these includes the following:
1. Reduction in the venous and lymphatic microcirculation.
2. Increase in fat deposits,which in conjunction with reduced catabolism,
leads to thickening and hardening of the connective tissue.
3. Increased mass leads to increase in fat deposits with a reduction in
venous and lymphatic microcirculation. This in conjunction with
reduced catabolism and thickening and hardening of connective tissue
causes cellulite.
It must be remembered that there is little correlation between excess
adipose tissue and cellulite. There are many thin females who have the
appearance of cellulite on their bodies, whereas some heavier females may
display only a subtle appearance of any cellulite (Fig. 10.2).
Fig. 10.1: A comparison between the orientation of connective tissue between

men and women accounting for cellulite
Fig. 10.2: Comparison of normal and cellulite tissue
Assessment Tools
Cellulite can be assessed by direct observation with side lighting. Based upon
these observations, a relatively simple scoring system for the appearance
of cellulite has been described, (Table 10.1) though very little data exist on
grade-specific therapeutic measures.
Treatment of Cellulite
There are two main goals for treating cellulite: 1. Tighten and strengthen lax
connective tissue and bolster underlying subcutaneous fat. 2. Target and
reduce the actual subcutaneous fat that contributes to the lumpy surface
appearance of cellulitic skin.
Nonablative modalities that selectively focus thermal injury into the
dermis while sparing the epidermis, such as radiofrequency devices, are used
commonly to tighten facial skin and may also produce similar effects in patients
with cellulite. Targeted reduction of subcutaneous fat with nonablative laser
devices and focused ultrasound is also being tried. Anderson et al. recently
showed that the 1,210 and 1,720 nm wavelengths, wherein the absorption
coefcient of human fat is greater than that of water, may allow selective
heating of adipose tissue with minimal damage to surrounding structures.
There are no commercially available devices utilizing these wavelengths.
The treatment armamentarium targeted toward cellulite includes
weight loss, topical pharmacologic agents, and physical mechanisms. The
main pharmacologic treatment options include methylxanthines (caffeine,
aminophylline, and theophylline) and retinol. Interestingly weight loss itself
does not help in treating cellulite (Table 10.2).

Table 10.1 Grading of cellulite
Phase 0
Phase 1
Phase 2
Phase 3
Even skin when

standing
Even skin when

standing and lying
Even skin when

lying down
Always dimpled skin
Pinch test only

few dimples
Pinch test shows

dimpled skin
Dimple skin when

standing
Table 10.2 Overview of therapeutic modalities for cellulite/obesity

Device based
Others
Radiofrequency devices (Celluite)

1. VelaSmooth:* bipolar RF, infrared heat, and suction
device
2. Alma Accent RF System (Alma LasersTM,
Israel)Unipolar and bipolar radiofrequency
3. ThermaCool (Thermage, USA) : unipolar
radiofrequency
Both of these devices are FDA approved for rhytides. Only
the Alma System and the VelaSmooth have been studied
in peer reviewed journals.
Botanicals
Garcinia cambogia
Caffeine
Piper nigrum
Ginkgo biloba
Centella asiatica
Papaya
Green tea
Endermologie (Cellulite)
Light sources and massage (Cellulite)
1. TriActiveTM (CynosureTM, USA)* : 810 nm diode laser
with vacuum massage
2. Synergie esthetic Massage SystemTM (Dynatronics,
USA):* Vacuum massage with or without a 660880 nm
probe or 880 nm light pad
3. SmoothShapes (Elem Medical, USA)*
915 nm laser and 650 nm light source combined with
vacuum and mechanical massage.
Weight loss ?
Laser-assisted liposuction (Adipose tissue)
LED plus topical

phosphatidylcholine-based gel
Ultrasound(Adipose Tissue)
Mesotherapy
Intense Pulsed Light(Cellulite)
Liposuction
Subcision
*FDA Approved for cellulite ,Published studies
Though most of the procedures listed (table 10.2) can be used for cellulite,
as the pathogenesis has multiple factors including fibrosis, circulatory
failure, and an underlying metabolic failure, no single therapy is effective. Of
the available devices on the market, those with radiofrequency seem to have
the most effect. These devices do not yield more than a 50% improvement in
most subjects. Most do not employ clearly objective means of proving clinical
efcacy, casting doubt on the true efcacy of these devices.
Laser Lipolysis
To understand how noninvasive body shaping works, it is important to
understand how fat is metabolized and stored in the human body. Whenever
the caloric intake exceeds demand, the excess energy is stored in the form of
triglycerides in the specialized cells called adipocytes. Such cells are present
in various body areas, but for the purpose of noninvasive body shaping, we
will concentrate our attention on the adipocytes in the skin which make up
the subcutaneous fat layer.
The adipocyte is a cell with a large amount of cytoplasm capable of storing
a large amount of triglycerides. These form the energy reserve of the body.
The number of adipocytes is regarded to be fixed, but their size can show great
variability. When enlarged, they disrupt the natural body contours resulting
in local fat collection and, in extreme cases, obesity.
So, how does one go about decreasing fat in the subcutaneous layer? There
are only two wayseither decrease the cell number or decrease their size. The
former is accomplished by methods which either mechanically remove fat
cells, such as liposuction or by methods which cause adipocyte death through
one mechanism or the other. The latter involves getting the adipocyte to give
up its triglyceride content through membrane manipulation. The released
TAG is transported from the interstitial space to the lymphatic channels
from where it is metabolized by the liver. Numerous studies have shown
the safety of these techniques, and there have been no reports of fatty liver/
liver dysfunction or increased serum triglycerides following noninvasive fat
reduction techniques.
The first mechanism, adipocyte removal or death, offers longer-lasting
results than adipocyte fat removal, since as mentioned earlier the number of
adipocytes is fixed throughout life. However, since the remaining adipocytes
can increase greatly in size to compensate for the numbers lost, it is essential
that lifestyle modifications (i.e. diet, exercise) are done on a sustained basis
by the patient to maintain desired results. This is even more important with
the more temporary method of fat removal from a viable adipocyte. There are
three mechanisms of removal of fat (TAG) from the adipocytes:
1. Thermal augmentation of normal metabolic processes of the fat cell.
2. Thermal or cavitational destruction of fat cells.
3. Creation of a temporary pore in the fat cell membrane.
A signicant barrier to noninvasive treatments is the issue of fat localization
after treatment. Adipose tissue stores triglycerides. Unlike cholesterol, which
can be excreted, triglycerides are not excreted by the body; in fact, they are
stored and used for such molecules as plasma lipoproteins. Thus, the removal
of large deposits of subcutaneous fat may yield redistribution to other
sites in the body. Since increased visceral fat has been linked to increased
cardiovascular disease, noninvasive therapies should be approached
cautiously, and their use may be limited to treatment of small deposits of fat.
Assessment Tools
Body mass index (BMI = persons weight in kilograms divided by the square
of their height in meters) remains the classic method for determining obesity.
But this has issues as many patients presenting for noninvasive body sculpting
may be in very good shape overall with only a few small problem areas such
as the thighs or flanks.
Thus, for laser procedures, thigh circumference, waist circumference,
skinfold thickness, visual assessment, and photographic comparisons, preand post-procedure are more useful
Indications and Contraindications of Non Invasive Body Contouring

Indications
Realistic expectations of a modest reduction of localized fatgenerally,
only soft tissue deformities with at least 1.5 cm of fat thickness should be
treated
Patient opposed to a surgical procedure for fat reduction
Compliance with multiple visits for procedures.
Contraindications
Pregnancy
Patients with a pacemaker
Patient with a serious or debilitating medical illness
Patients with a large BMI
Unrealistic expectations.
Treatment Devices
Though we are listing the devices below it must be understood, just what one
intends to treat. Table 10.2 gives an overview of the devices being used and
identifies the device that can be used for a particular indication, i.e cellulitis
of obesity.
Suction/Massage Devices
These are amongst the oldest machines available for noninvasive fat loss.
Endermologie is a technology that originated two decades ago in France
that uses paddles coupling suction and a roller to stimulate fatty areas. The
concept is that lymphatic circulation in the treated area is stimulated resulting
in mild fat loss from adipocytes. In selected patients, particularly those with
edematous type of fatty deposits, the procedure can result in measurable
circumference reduction. For most people, the improvement is very mild and
the machine is mostly used in the day spa environment.
Endermologie (LPG Systems, Valence, France) is an FDA-cleared device

that massages and kneads the skin to improve the appearance of cellulite.
This is supposed to work by stimulating blood and lymphatic flow, thereby,
altering the architecture of the fat and improving the appearance of cellulite.
The results though are modest both in the appearance of fat and cellulite.
Newer machines take the above concept further by coupling the suction
with transepidermal thermal energy delivery (Table 10.2). This thermal
energy is generated with the help of diode arrays or nonfocussed ultrasound
around the probe head. TriActiveTM (Cynosure, Inc.,Westford,MA,USA) and
SmoothShapes (Cynosure, Inc., Westford, MA, USA) are two such devices.
Again results are modest and these machines are often used in as adjuncts
to other fat removal methods (e.g for smoothening out results and tightening
skin after surgical liposuction).
Radiofrequency Energy Devices

These are the most popular noninvasive fat loss devices in the world.
Radiofrequency devices can be classified into multiple types (Box 10.2), but
unipolar, bipolar or multipolar devices are commonly used.
How do they Work?

Bipolar RF devices are based on the principle of heat generation as a result
of poor electrical conductance, as the RF waves pass through fat. the
resulting heat is strong enough to cause thermal damage to the adipocytes
and connective tissue septae. Adipose tissue has high tissue resistance and
Box 10.2
Body contouring devices*
1. Suction: Massage devices

a. Endermologie
2. Suction-massage: Thermal devices

a. TriActiveTM (Cynosure, Inc.,Westford,MA,USA)

b. SmoothShapesTM (Cynosure, Inc., Westford, MA, USA)
3. Radiofrequency energy devices

a. VelaSmooth, VelaShape (Syneron, Inc., Irvine, CA, USA)

b. Thermage (Solta Medical, Hayward, CA, USA)

c. AccentTM (Alma Lasers Inc, Buffalo Grove, IL, USA)

d. TiteFXTM (Invasix, Inc., Yokneam, Israel)
4. High-frequency focused ultrasound energy devices

a. UltraShapeTM (UltraShapeLtd.,Yoqneam, Israel)

b. LipoSonixTM (Medicis, Scottsdale, AZ, USA)
5. Cryolipolysis energy devices

a. ZeltiqTM (zeltiqaesthetics, pleasanton, CA, USA)
6. Low-level light laser therapy devices
a.
ZeronaTM (Erchonia Medical, McKinney, TX, USA)
7. Microwave by thermolysis
*As proposed by Mulboland et al.
arelatively low heat transfer coefficient; thus, adipose tissue can be readily
heated, and the heat will be predominantly confined to the adipocytes.
Bipolar RF devices have a penetration depth of >3 mm and allow for
better control and localized adipose tissue alteration. Unipolar devices utilize
high frequency electromagnetic radiation (EMR). High frequency EMR
induces high frequency rotational oscillations in water molecules, which
in turn produce heat, i.e. greater the presence of water, greater is the tissue
heat generation. The depth and breadth of thermal damage is greater and in
a rather diffuse pattern with little control as compared to bipolar RF devices.
The end result is the creation of dermal brosis through neocollagenesis
or so-called appearance-enhancing scarring that leads to long-term
improvement after fewer treatments. The heat generated increases adipocyte
fat turnover but does not kill the adipocyte.
Unipolar and bipolar RF technologies also exist as combination Accent/
Alma device (Alma lasersTM, Buffalo Groove, IL). The Alma Accent RF system
(Alma lasers, Buffalo Groove, IL) and ThermaCool (Thermage, Hayward,
CA) utilize RF and may be useful in the treatment of cellulite. Both the Accent
and ThermaCool are FDA approved for the treatment of wrinkles and rhytides.
The ThermaCool is a unipolar RF, while the Accent system is a unipolar and
bipolar RF device. Of the two devices, only Accent system has been evaluated
for the treatment of localized adiposities (Table 10.2).
VelaSmooth and VelaShape

VelaSmooth was the first RF based device approved for cellulite reduction
by the FDA in 2005. This was followed two years later by the higher powered
VelaShape which has since then undergone three revisions. VelaShape is
FDA approved for both cellulite and circumference reduction. This machine
uses a combination of radiofrequency energy as well as infrared light
wavelengths to treat cellulite noninvasively. The infrared light spectrum
ranges from 680 to 1500 nm and can possibly penetrate up to 5 mm below
the skin.
Both VelaSmooth and VelaShape systems combine Infrared light (700
nm to 2000 nm) with suction coupled Bipolar RF (1 MHz) and mechanical
manipulation, the difference being that VelaSmooth is rated at 25 W while
VelaShape is rated at 50 W and is thus more powerful. During treatment
suction is used to pull the skin into the handpiece where the skin is exposed to
IR and RF while its surface temperature is being monitored. IR mainly targets
dermal water while RF targets the deeper dermis and subcutaneous fat layer.
The resulting heat stress causes dermal contraction and stimulates increased
vascular flow and neocollagenesis and in the subcutaneous layer increases
the metabolism of the adipocyte resulting in TAG removal from the cell. The
suction and mechanical massage from the probe stimulate lymphatic flow
further enhancing fat removal.
Results: In the largest study of VelaSmooth, Sadick evaluated 35 patients

who completed either 8 or 16 treatments with VelaSmooth. A blinded
dermatologist evaluated the photographs and found 40% improvement on
average in cellulite appearance, and there was a circumference reduction in
all. Numerous studies have repeatedly shown the efficacy of VelaSmooth in
improving cellulite, but a few studies have shown circumference reduction as
well ranging from 1.25 to 3.5 cm on the abdomen and thighs and 0.50.75 cm
on the arms.
A more recent study of VelaSmooth found a statistically significant
decrease in thigh circumference at 4 weeks, but no immediate change or a
persistent decrease at 8 weeks. Visual improvement of less than 50% was noted
in the majority of subjects and 31% of the subjects experienced bruising.
Hence, it seems that cellulite reduction remains the main application of
the machine. Sessions vary from weekly to biweekly and number of session,
from four to sixteen. Benefit is seen as early as one month, and in one Asian
study was sustained over one year.
Unipolar RF Devices
Thermage and Accent are two prominent unipolar (monopolar) RF devices
employing pure RF without adjunctive IR or suction coupling. The limitation
of RF is that the energy is not specific, unlike ultrasound waves, and their
depth of penetration into the skin is limited unless very high levels are used.
Hence, both treatments are more suited to nonsurgical skin tightening than
fat reduction. Cellulite is superficial fat as compared to the subcutaneous fat
layer, and hence, this may improve as well. Both machines can be associated
with significant discomfort during the procedure.
Results: Studies have assessed Thermage in the treatment of cellulite with
improvement scores ranging from 30 to 70%, 6 months post-treatment.
Accent is similar to Thermage and uses high frequency RF for skin tightening,
cellulite reduction and modest circumference reduction.
Goldberg et al. studied the use of the Accent unipolar RF device for
cellulite treatment. Their study included subjects with higher grade cellulite of
upper thighs. They were treated every other week for a total of six treatments.
Results obtained 6 months after the last treatment showed an average 2.45 cm
reduction in thigh circumference with minimal side effects, and no changes
in serum-lipid abnormalities, and MRI were seen. They attribute their longerlasting effects to the formation of dermal brosis in the upper dermis and
increased contraction between the dermis and campers fascia, which has
been previously reported in ultrasound imaging studies. The presence of
thickened dermal brous band or so called scarring is concerning regarding
long-term effects.
It is known that postmenopausal women tend to lose more weight in the
femoral area as compared to premenopausal women, who tend to gain more.
For women who would undergo unipolar RF treatment in their reproductive

years might lose weight later on. Since scarring induced by unipolar RF devices
is permanent, long-term improvement is questionable and concerning.
Tripolar Radiofrequency
TriPollarTM (Pollogen, Tel Aviv, Israel) and FreezeTM (Venus Concepts) are
some other RF machines. TiteFxTM is a variation on the RF concept and uses
suction coupled RF to heat the dermis and first 1.52 cm of fat. When the
epidermal temperature reaches 43 to 45 C, a high-voltage, electroporation
pulse is generated through the adipose tissue resulting in damage to the
adipocyte membrane and resultant apoptocysis over the following week. The
device is much quicker than Thermage making the treatments more tolerable.
Conclusion
Though most of these devices have been used for skin tightening some have
a potential for use in cellulite. There are issues with most of these devices ,
notably the lack of adequate histological confirmation in most and of course
lack of sustained results !
High Intensity Focused Ultrasound (HIFU)

Ultrasound devices for fat reduction can be divided into those using nonfocused versus focused high frequency ultrasound. Nonfocused ultrasound
(NFU) devices just have a dermal heating effect with minimal or no fat
reduction; hence, our discussion with focus on HIFU.
How does it work ?

In a conducive setting, ultrasonic energy affects tissue destruction through
three mechanisms: cavitation, micromechanical disruption, and thermal
damage. It is thought that cavitation is predominantly responsible for tissue
destruction in internal ultrasound assisted liposculpting (UAL). NFU devices
lack the ability to cause cavitation and, hence, are not effective for fat loss.
It is postulated that external ultrasound prior to liposuction works either
through thermal or micromechanical effects.
A nonablative thermal treatment would not be expected to have a
signicant or durable effect on fat. In fact, external nonfocused therapeutic
ultrasound has been applied to body contouring but was found to be effective
only as an adjunct to tumescent liposuction, improving tissue hydration and
distribution of the tumescent solution.
Ultrashape
Transdermally focused Contour I UltraShapeTM (Tel Aviv, Israel) uses focused
ultrasound to deliver a nite amount of acoustic energy at a controlled
distance from the ultrasound transducer to achieve noninvasive body

contouring.
Ultrasound energy is emitted from a hemispherical transducer (fig. 10.3).
The energy is low near the transducer surface and is concentrated in an
additive manner at a distant focus. The transducer is placed directly on the
skin and focuses the energy at the depth of the subcutaneous fat. As a result,
the energy can be delivered through the skin, with low energy density at the
epidermis and dermis, and with a high energy density in the subcutaneous fat.
The ultrasound energy is delivered in pulses, using parameters that provide a
nonthermal effect. High levels of ultrasound energy within the subcutaneous
fat can disrupt adipose tissue safely and effectively, as has been demonstrated
in ultrasound-assisted liposuction. Tissue selection is achieved partly due to
the pulsed nature of the pulses and party due the differential susceptibility of
different tissues to mechanical (non-thermal) stress.
Results: A prospective, non-randomized, controlled trial (n = 164 patients)
conducted by Teitelbaum et al. found that after one ultrasound treatment
to the abdomen, thighs, or flanks there was a after 12 weeks a mean
circumference reductions of 2.3 cm (abdomen), 1.8 cm (thighs), and 1.6 cm
(flanks). The majority (77%) of the improvement in circumference was noted
to occur within the first 14 days following the treatment.
Interestingly, one Asian study failed to demonstrate much improv
ement53 patients were treated with 3 sessions spaced a month apart
and there was no significant difference in the pre- and post-treatment
parameters, such as circumference reduction, ultrasound fat thickness
and skin caliper fat thickness. This has been hypothesized to be because
Fig. 10.3: A figurative depiction of focused USG used for fat reduction
of body habitus difference between Asians and Caucasians. Since then the
UltraShape has undergone two revisionsthe so called second and third
generation UltraShapewith software upgrades and better transducers. The
third generation UltraShape also has 2 additional technologies built into it
advanced nonthermal selective focused ultrasound and vacuum-assisted RF
combined. These 2 technologies allow same-session combination therapy,
facilitating a synergistic treatment protocol, thus, producing a complete
body-contouring solution. Over 200,000 UltraShape treatments have been
performed worldwide with no reports of any significant adverse event.
The procedure is comfortable and patients start seeing a difference within
a month. In general, an average of 24 cm of circumferential fat reduction
can be achieved over 3 sessions spaced 2 weeks apart from the abdominal
and hip regions, and about 23 cm from the inner and outer thighs. With the
third generation machine, it is anticipated that this can occur after a single
treatment.
LipoSonixTM
LiposonixTM is the other main HIFU system; however, it differs significantly
from UltraShape in several parameters. Liposonix uses two HIFU rays to
focus on a very localized area causing rapid heating (> 56 C) of the tissue,
with a variable focal depth of 1.11.8 cm. This causes coagulative necrosis of
the fat cell and instantaneous cell death. So, the effect is thermal as opposed
to the non-thermal effect of UltraShape. This also makes the procedure quite
painful and sedation is required in contrast to UltraShape, which requires
none. Distilled water needs to be used as a coupling agent to prevent acoustic
reflection of the high frequency ultrasound waves from air pockets in
between the transducerskin interface. Adverse events seen include swelling,
ecchymoses, dysesthesia, and pain on treatment, unlike UltraShape which
has virtually no side effects. Fewer sessions are required with the Liposonix
though with studies showing 25 cm circumferential reductions after a single
sitting.
Results: Studies have shown significant improvement following a single
treatment session. But a high intensity dose setting is helpful and is associated
with more pain, bruising, and edema.
Summary
Although Contour I UltraShapeTM is widely used for noninvasive body
contouring, data regarding the long-term efcacy and persistence of
satisfactory results is still lacking. Whether the treated patients will require
regular treatments for maintenance of achieved results indenitely, is still
unanswered.
Lightbased Devices and Laser-assisted Lipolysis (LAL)

Laser lipoplasty with pulsed neodymium, yttrium, aluminum, garnet
(Nd:YAG) laser, also called interstitial laser lipolysis was rst described in 1994.
This technique is widely used in Europe and Latin America and has recently
been introduced in Japan and the United States. Less trauma, bleeding, and
pain have been the main advantages of this technique (Table10.2).
How Does it Work ?

The mechanisms leading to laser lipolysis is largely temperature dependent.
At low-energy settings, tumescent adipocytes were observed. At higher
energy settings, cytoplasmic retraction, disruption of membranes, and heatcoagulated collagen bers are seen.
The various devices used have to be understood in respect to the absorption
spectrum as given in the Table 10.3 that shows an ideal wavelength seems to
be 1440 nm. Wavelengths, such as 1210 nm and 1720 nm are highly specific
for lipids, but there are no devices at present with these wavelengths.
Devices Used
Pure Laser Devices
1. The Nd:YAG laser was rst used in laser lipolysis, because of the
penetration depth of its wavelength (1,064 nm). The Nd:YAG laser has
been used alone or in combination with suction liposuction. SmartLipoTM
(Cynosure, USA), a 300 m ber encased in a micro-cannula, is an
example of this type of device. The cannula is inserted subcutaneously
to destroy lipid membranes and release lipids. Adipocytes appear to
swell at lower energies and lyse at higher energies. The laser heat also
coagulates collagen bers. This process is termed as laser lipolysis
(Ichikawa K). Strictly speaking, lipolysis is dened not as destruction
of the adipocyte membrane, but rather as shrinkage of the fat cell due to
the use of lipid for energy at the cellular level.
2. Diode lasers, which can typically emit at 810, 940, and 980 nm, is another
alternative. Their wavelengths are in the same spectral region as 1064nm,
Table 10.3 Absorption spectrum of various wavelengths
Wavelength
Fatty Tissue/Water Absorption
924 nm (Diode)
2.8/1.4
980 nm (Diode)
1.7/3.6
1064 nm (Nd:YAG)
1/1
1320 nm(Nd:YAG)
5.9/11.5
1440 nm(Nd:YAG)
127/252
and they offer the advantages of higher efciency (usually 30%) and
higher power (25 W or more). The absorption spectrum of mammalian
fat obtained by VanVeen et al. using three independent methods show
that the absorption coefcient obtained with a wavelength of 980 nm is
very similar to that obtained with a wavelength of 1,064 nm.
3. 1440 nm lasers: Based on the absorption spectrum as given in table
10.3 the ideal wavelength for fat absorption is 1440 nm. The 1440 nm
wavelength is highly absorbed in adipose tissue, which is composed of
75% fat, 20% water, and 5% proteins. This is as the 1440 nm wavelength is
absorbed by adipose tissue 127 times greater and absorbed by water 252
times greater than the 1064 nm wavelength.
Cellulaze (Cynosure) is a laser device that uses a 1440-nm Nd:YAG
fiber with a novel delivery system to target the structural components
of cellulite. The technology incorporates a unique SideLight SideFiring Fiber as well as a ThermaGuide thermal sensing system for safer
treatments.
4. 635 nm laser and liposuction: Neira has combined low level 635 nm
laser and liposuction in a technique labeled the Neira 4 L technique.
Patients are irradiated with a low-level 635 nm laser after tumescent
anesthesia. Following irradiation, removal of fat is accomplished with a
cannula or other technique. Neira postulated that low level laser creates
a pore in the adipocyte membrane, causing leakage of lipid into the
interstitial space. He studied 12 patients and found that after 6 min of
low level laser, fat was completely removed from the cell.
Combined Devices
1. The SmoothShapes (Eleme Medical, Merrimack,NH, USA) device for the
treatment of cellulite is a dual wavelength, 915 nm and 650 nm, laser
device that is combined with a vacuum-assisted mechanical massage.
The basis of these wavelength selections is based on adipose samples
treated with a 635 nm light from a 10 mW diode laser, which showed
emptying of fat from these cells (Neira R ). Then the 915 nm wavelength
penetrates into the tissue and is preferentially absorbed by lipids, causing
a thermal effect. The temperature inside the adipocyte is elevated by up
to 6 C.
The 650 nm wavelength is thought to modify the permeability of the
fat cell membranes, allowing expressed fat to move into the interstitial
space, without ever destroying the adipocyte cell membrane. The fat is
moved into the interstitial space and lymphatic system for elimination
with the aid of mechanical rollers and mild suction. Without the use
of rollers and suction, the fat would return into the adipocyte within
45minutes.
2. The TriActive device (Cynosure Inc., Bedford, MA) combines deep

tissue massage and suction (similar to Endermologie), with contact
cooling and a low-intensity diode laser (808 nm).
The TriActive (Cynosure, Westford, MA, USA) platform used 3
components to treat cellulite specifically: contact cooling, massage,
and a diode laser. It has been shown that the diode laser component
significantly contributed to clinical improvement.
Work done by Nootheti PK et al. compared the efcacy of treatment of
cellulite using TriActive vs. VelaSmooth. Patients were treated twice
weekly for 6 weeks with either VelaSmooth or TriActive. They calculated
a 28 vs. a 30% improvement rate, respectively, in the upper thigh
circumference measurements, while a 56 vs. a 37% improvement rate
was observed, respectively, in lower thigh circumference measurements.
Statistical signicance of these results was p > 0.05. Incidence and extent
of bruising was higher in VelaSmooth than in TriActive system, which
may be attributed to mechanical manipulation.
3. The VelaSmooth and VelaShape (Syneron Medical Ltd, Irvine, CA)
devices, as discussed previously, combine physical manipulation
with radiofrequency energy, as well as infrared energy, to facilitate a
multimodality approach to fat and cellulite treatment.
Procedure
Patient Selection: This is a crucial part of delivering results with LAL. The
ideal patient should be thin with localized pockets of fat that need treatment.
The patient should be in good health. The need for maintaining a healthy
lifestyle (diet, exercise) after the procedure should be emphasized, and
there should preferably not be a history of frequent or rapid weight gain and
weight loss in the past. The patient should have realistic expectations from
the procedure, and it must be clearly explained before hand that LAL is not a
method of weight loss but of body contouring.
Any areas with unwanted adiposity can be treated with LAL. Commonly
treated areas are the abdomen, flanks, submental region, upper arms,
buttocks and thighs. Other areas like the knees, calves, ankle, breast, lipomas
and localized adiposities left from previous liposuctions can also be treated.
Contraindications
Absolute
Pregnancy
Bleeding diathesis
Lignocaine allergy
Serious debilitating illness of any kind.
Relative
Compromised liver function
Age over 65
Hypertension
Diabetes
Cardiovascular problems.
Preoperative Workup
Standard preoperative investigations that must be done in every patient
include CBC, liver function tests, blood sugar, kidney function tests, lipid
profile, HIV, HBsAg, anti-HCV, bleeding parameters, and in the case of
women, a urinary pregnancy test, if applicable.
Surgeons differ in their use of preoperative medications, and the experts
do not recommend any routine medications.
Techniques
1. The part to be treated is clearly marked out in a standing position. This
is important because once the patient is lying down and tumescent
anaesthesia has been administered the contours can change
dramatically.
2. There should be at least 1.5 cm of fat in the pinch test in the area to be
treated (fig. 10.4).
The decision must be made whether suction will be employed after laser
lipolysis. In smaller areas like the submental region and inner thighs
suction is not required while larger areas like the abdomen usually
benefit from suction.
3. The procedure is performed under tumescent anesthesia. For this, a
tumescent solution is prepared using lignocaine with epinephrine,
sodium bicarbonate, and normal saline. The concentration of the
lignocaine is between 0.050.1% depending the region being treated
and that of 1:1,000,000 epinephrine is usually 0.050.75 mg/L. 10 meq
of sodium bicarbonate is added to each liter of the tumescent solution
to raise its pH and thus prevent stinging (lignocaine is acidic in nature).
The maximum safe dose of lignocaine in tumescent anesthesia is 55 mg/
kg; however, experts recommend keeping the concentrations at a more
conservative 3545 mg/kg for additional safety.
4. The next step is to make access ports around the area to be treated.
These can be made as small stab incisions with a No.11 blade or with a
1.5 mm punch, after infiltrating 1 ml of 12% lignocaine with 1:100,000
epinephrine at each site. The number of ports depends on the area being
treated and a typical number for the abdomen is 46. The tumescent
solution is then infiltrated gradually into the entire area to be treated.
This can be done using large syringes (50 ml) or with specialized
Fig. 10.4: Preoperative preparation for laser assisted liposuction (QuadroStar+ 980
(Diode laser)
devices, such as infiltration pressure cuffs. Because of the large volume

required in areas, such as the abdomen (23 L), this step can take 4560
minutes or more. About 30 minutes must be given after all the solution
has been infiltrated to allow proper diffusion and adequate anesthesia
before commencing the procedure.
5. After this, the fiberoptic cable carrying the laser is inserted through
stainless steel cannulas and then introduced in the subcutaneous plane.
The cannulas can be inserted empty to begin with and a tunneling to and
fro motion used to create an easier path, once the laser is introduced.
The laser cable extends 2 mm beyond the steel tip of the cannula and is
visible as a bright red light shining through the skin. As the laser is fired
the cannula is moved slowly to cover the treatment field. On an average
10 passes are required to adequate laser lipolysis. There is a reduction in
volume of the treated area, felt with the finger pinch test, and this serves
as a tactile marker of the end point for lasing (fig. 10.5).
6. Once this is done the suction apparatus is attached to the stainless steel
cannulas and the liquefied fat from the laser treated areas is aspirated.
Fig. 10.5 : A depiction of the procedure planes in laser assisted liposuction
Typically 25 L of fat can be removed from areas, such as the abdomen.

This step takes 1.52 hours to complete.
7. In the end, the ports are dressed (not sutured) and a compression
garment is applied to support the treated area. The patient is then sent
home on antibiotics and painkillers.
Advantages of Laser-assisted Liposuction

1. Shorter recovery time. Most patients able to go back to work within 23
days.
2. Less bruising and edema and hence, less post-procedure pain.
3. Less trauma during the procedure due to smaller size of the cannula
used.
4. Skin tightening is perhaps the most important benefit of LAL as
compared to suction assisted liposuction (SAL).
5. More uniform fat reduction and hence smoother external appearance.
6. Lower rate of revision surgeries (3.5% as compared to 1213% with SAL).
7. Limited role in improving cellulite as compared to SAL, which is
ineffective for this indication.
Limitations of Laser-assisted Liposuction

1.
2.
3.
4.
5.
High cost of the laser machine.

Increased procedure time as compared to SAL.
Risk of thermal injury (skin burns).
Unsuitable to treat large areas.
Steeper learning curve as compared to suction-assisted liposuction.
Summary
Laser lipolysis is a new technique still under development. The use of 1,064
nm-Nd:YAG and the 980-nm diode laser as an auxiliary tool has rened the
traditional liposuction technique. For given energy settings, 1,064 and 980nm wavelengths gave similar histologic results (figs 10.6A and B).
Recently DiBernardo reported that the use of a 1440 nm laser subdermally
could disrupt and reduce herniated fat in the dermis, through a process of
tissue coagulation. They demonstrated ultrasound evidence of a 25% increase
in skin thickness and a 29% decrease in skin laxity, which was maintained at 1
year.
We are particularly impressed with the study of Katz et al. where a
single treatment with the Nd:YAG 1440 nm wavelength laser was analyzed
by objective 2D and 3D photography (Vectra). Of patients, 62% showed
improvement at 3 months and 66% showed improvement at 6 months.
There are numerous advantages of LAL and it is a useful adjunct to
tumescent liposuction. But the smaller size of cannulas limits the ability of
this technology to be used on areas other than face, medial arms, knees, periumbilical, and perhaps medial thighs as a sole treatment.
Selective Cryolipolysis
There is evidence that adipose tissue is selectively sensitive to cold injury.
This is akin to cold-induced fat necrosis of the newborns and infants called
popsicle panniculitis and is the basis of this therapy (Box 10.1)
Figs 10.6A and B: (A) A 28-year-old female with localized adiposity in the lower
anterior abdomen and flanks; (B) Same patient 10 days after laser assisted liposuction
demonstrating a 3.5 inch circumference loss with minimal skin laxity and no bruising.
The access ports are visible on either side of the umbilicus and will gradually fade over
36 months. The abdominal skin will also tighten with time
How does it Work?

Cryolysis of fatty tissue is possible due to this biological selectivity. Biologic
selectivity refers to a specific response (e.g. inammation) that is conned to
a certain tissue (e.g. fat) on account of a stimulus.
Studies have revealed that a delayed, cold-induced lobular panniculitis is
involved. The adipose tissue loss continues for many weeks following a single,
local exposure to cold, reaching an apparent maximum at 4 weeks after and
resolving about 3 months after cold exposure.
Temperature and time of application are both important to induce
selective cryolysis of fatty tissue. A skin surface temperature as high as 1C
induced can induce a mild panniculitis within the various tested anatomical
locations and the anatomic depth of panniculitis and of fat loss is increased
when lower temperatures are applied.
Results and Summary

Work done by Anderson et al. has suggested that lipid crystallization is
perhaps responsible for lipoatrophy seen in their Yucatan pig models. This
mechanism will pose challenges to the development of selective cryolysis for
clinical use, as pigs have a higher content of saturated fatty acids compared
to unsaturated ones. Additionally, it is not apparent that the intracellular
crystals seen in adipocytes were large enough to elicit the inammatory
panniculitis, largely responsible for producing the effects.
Zeltiq (Zeltiq Aesthetics, Pleasanton, CA, USA) is the main cryolipolysis
device available in the market and is FDA approved for treating the
abdominal flanks (love handles). The part to be treated is sucked into the
probe with mild suction and then held between the panels for 3060 minutes
at a sub zero temperature. Once the probes are removed, the area is red and
feels frozen solid and numb. This numbness can persist for 23 months but
there are no reports of permanent nerve damage. Studies have shown a 25%
reduction in the fat content of the treated areas. No systemic side effects have
been seen. The machine does not require a technician to operate but has the
disadvantage of long treatment time and a high disposable cost.
Conclusion
Many important details about selective cryolysis remain to be studied. Most
importantly, there is not enough information available in published literature
regarding the mechanisms of adipocyte injury in adult humans when subzero temperatures are applied to a fold of skin suctioned in between two cold
applicators, for varying times. At this point, we know little or nothing about
the longevity of the fat lost as a result of selective cryolysis. The possibility of
fat regenerating itself after a certain period of time still remains. Finally, there
is a question of the fate of fat. Although in the study done by Anderson et al.
no signicant rise in serum lipids was seen, the possibility of fatty inltration
of liver cannot be excluded.
Cryolipolysis represents a novel, non-invasive treatment option for fat.
Patients can undergo a safe, effective, and simple procedure, which will
gradually reduce the appearance of unwanted fat over the following 24
months. It should be noted that the device works best for localized, discrete
fat bulges and is not intended for the treatment of obesity or as a substitute for
large-volume liposuction.
Acoustic Waves
These are radial mechanical wave, which have penetration depth of about
2530 mm. A comparison with comparator technologies is depicted in Figure
10.7. The acoustic wave (a particular family of shock waves) penetrates the
skin (fig.10.7) and the maximum energy density is at the surface and rapidly
decreases with increasing penetration (with 1/r).
They are used for local fat deposits and work by:
1. Altering the Osmotic balance.
2. Improvement of intra-/extracellular metabolism.
3. Increase in cellular metabolism in the adipose tissue.
4. Improved tone of connective tissue.
Indications
Localized fat deposition on the upper arm, abdomen, hips, buttocks, thighs,
and inner thighs.
Results
Various studies have been published on this technology largely from Europe,
which show that the technology is effective in localized cases of cellulite. But
more studies are needed to validate these findings (Fig. 10.8).
Fig. 10.7: A comparison of acoustic waves with different ultrasound systems
Fig. 10.8: A case of localized adipose tissue deposition treated by AW technology

(Ascepelion laser technologies, GmBh)
Issues and Controversies with NonSurgical Sculpting

Cellulite is a well-documented condition, and although many treatment
options have been used, few have lasting clinical results. This historically
notorious problem will always be the focus of device technologies, but
considering the multiple mechanism involved in cellulite, we feel that
technology may not by itself help in this condition.
Depending on the grade and severity, some cellulite patients may see a
lesser degree of improvement. It is important in the consultation to address
patient expectations. Noninvasive treatments require multiple treatments as
well as possible interval maintenance treatments. Resistant cases could be
due to severity of the case or undertreatment of the area. When using laser,
radiofrequency, or ultrasound devices, it is important not to deliver excessive
fluences, as this could lead to unwarranted treatment, complications, and/or
thermal damage.
There are other issues, which have to be ironed out. It is important to see
all patients in follow-up. Measurements to be taken include dimple severity,
circumference, and overall laxity. Patient satisfaction should also be assessed.
The use of traditional 2D imaging as well as 3D imaging can augment followup visits. Patient satisfaction to be given an objective comparison from
baseline.
The controversies and unanswered questions with regard to laser lipolysis
are many and include lack of standardized treatment protocols and the
amount of the tumescent fluid to be used in laser-assisted liposuction. If too
little fluid is used, the anesthesia is incomplete. If a proper supertumescence
is applied, much of the laser energy is absorbed by the infiltrated fluid instead
of the tissue. The most effective energy that can be delivered with the fewest
side effects has not been determined. Lastly, the best way to move the
handpiece through the subcutaneous tissue: release of the laser energy only
when pulling back or during a back and forth movement; moving slowly and
evenly or faster and in a more random way is another vexing issue.
Thus, at present laser lipolysis is to be used mostly in conjunction with

tumescent liposuction. Because the same risks and side effects apply, the
surgeon should be well trained and experienced in liposuction surgery and
untrained dermatologists should not venture into the invasive procedures. As
fat reduction is a cosmetic and commercial necessity, a lot of refinements are
needed, and thus, this will continue to be a topic of active future research.
Thus, at present with little comparisons between the various methods, it
is difficult to decide which is the ideal device. But if a substantial end result is
the aim, laser-assisted liposuction seems to be the best bet at present in our
opinion.
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18. Teitelbaum SA, Burns JL, Kubota J, et al. Noninvasive body contouring by
focused ultrasound: safety and efficacy of the Contour I device in a multicenter,
controlled, clinical study.Plastic and Reconstructive Surgery. 2007;120(3):77989.
19. van Veen RL, Sterenborg HJ, Pifferi A, Torricelli A, Chikoidze E, Cubeddu R.
Determination of visible near-IR absorption coefcients of mammalian fat using
time-and spatially resolved diffuse reectance and transmission spectroscopy.
JBiomed Opt. 2005;10:054004.
Chapter
11
Lasers for Scars, Keloids,

and Stretch Marks
Kabir Sardana
Introduction
The psychosocial impact of cutaneous scarring can be profound. The
multifaceted causes of scars include traumatic incidents,surgical procedures,
and severe acne and can profoundly affect the quality of life of patients. We
will largely focus on the role of laser in nonacne scars in this chapter. Acne
scar have been discussed in the chapter of Fractional lasers.
EtioPathogenesis
Scars are the result of a deviation in the orderly pattern of healing and can
be caused by a variety of factors, such as excessive wound tension, improper
surgical repair, delayed reepithelialization, or a history of radiation to the
affected area. An excessive tissue response can create a raised nodule of
fibrotic tissue, whereas pitted and atrophic scars may result from inadequate
replacement of deleted collagen fibers. There are several currently available
scar reducing medical therapies, but we will largely focus on lasers.
Types of Scars
In medical literature, scars are often analyzed by their etiology, the most
common sources being surgery, trauma, burns, and acne or inflammatory
processes. While analyzing literature, the important parameters to assess
improvement include reduction of the redness and height of the scar,
improvement of pliability, and symptomatic relief of pruritus.
Hypertrophic Scars
They are erythematous, raised, firm nodular growths that occur more
commonly in areas subject to increased pressure or movement or in body
sites that exhibit slow wound healing. The growth of hypertrophic scars is
limited to the site of original tissue injury, unlike keloids, which proliferate
beyond the boundaries of the initial wound and often continue to grow
without regression.
Keloids
Keloids present as deep reddish-purple papules and nodules, often on the
earlobes, anterior chest, shoulders, and upper back. These lesions are more
common in darker-skinned persons and, like hypertrophic scars, may be
pruritic, dysesthetic, and cosmetically disfiguring. Whereas the histology of
hypertrophic scars is indistinguishable from that of other scarring processes,
keloidal histology may be recognized by thickened bundles of hyalinized
acellular collagen haphazardly arranged in whorls and nodules with an
increased amount of hyaluronidase.
There are a few salient differences between these two scars that are as
follows:
1. Hypertrophic scars are generally white to pink scars that remain within
the borders of the original wound.
2. These generally occur within 1 month of the injury and tend to improve
over time.
3. Keloids are composed of disorganized, thick, collagen bers with a
prominent mucoid matrix. Hypertrophic scars contain more organized
collagen bers within a scant mucoid matrix.
Atrophic Scars
These are dermal depressions that result from an acute inflammatory process
affecting the skin, such as cystic acne or varicella. The inflammation associated
with atrophic scars leads to collagen destruction with dermal atrophy. Surgery
or other forms of skin trauma may also result in atrophic scars, which are
initially erythematous and become increasingly hypopigmented and fibrotic
over time. Based on their width, depth, and 3-dimensional architecture, acne
scars are sometimes further subclassified into icepick, rolling, and boxcar
scars. They are discussed in the chapter on fractional lasers.
Prescars
These are early wounds in scar-prone skin. Prophylactic or early laser
treatment of traumatized skin concomitant with or shortly after cutaneous
wounding has been shown to reduce or even prevent scar formation in
patients at high risk for scarring.
Approach to Therapy
The scars should be treated depending on the type, stage, duration, color
and taking into consideration patient characteristics. Thus, an algorithmic
approach can be used (Flow chart 11.1) to first decide which laser to use,
which can then be tweaked depending on patient characteristics (Table11.1).
But, it must be appreciated that hypertrophic scars, if left alone, tend to
improve with time, and most of the studies published may have inadvertently
overlooked this fact.
Lasers for Scars, Keloids, and Stretch Marks 363

Flow chart 11.1: An overview of management of scars by lasers
Table 11.1 Parameters that determine laser therapy for scars

Characteristics
Variables
First line
Second line
Severity
Mild
Nonablative lasers
Ablative lasers
Moderate
Ablative lasers
Fractional (NAFR)
Severe
Ablative lasers
Fractional (AFR)
Type 13
All are equally good
Type 46
Fractional lasers
Skin type
Etiology
Patient choice
Burn scar
PDL
Fractional lasers
Surgical scar
Fractional lasers
PDL/ablative
Acne scar
Fractional lasers
Minimum downtime
Nonablative lasers
Some downtime
Fractional (NAFR)
Can tolerate
downtime
Ablative lasers
Ablative (CO2/Er:YAG), Fractional (NAFR/AFR)
Most of the hypertrophic scars have an average of 5080% improvement

after two laser treatments. Keloids, however, usually require more treatments
and/or other ancillary treatments, including surgical excision, to achieve
acceptable results.
Hypertrophic Scars and Keloids

Laser used: PDL, fractional laser, LED, PDT.
Initial studies used 1064 nm neodymium:yttrium-aluminum-garnet (Nd:YAG)
laser, argon, and carbon dioxide (CO2) showed promising results, but high
recurrence rates were observed. Thus, the most commonly recommended
system is the PDL, though it makes more sense to stratify therapy according
to the type of scars.
PDL
(Brewin MP 2014, Mamalis AD 2013)
PDLs have been shown to help in improving scar size, erythema, pliability,
pruritus, and texture and is used for all forms of hypertrophic scarring and
keloids, regardless of etiology.
Indications
Burn scars, sternotomy scars, acne scars, and facial scars resulting from
cutaneous surgery.
Mechanism of Action
1. Reduce expression of transforming growth factor beta, fibroblast
proliferation, and collagen type III deposition.
2. Selective photothermolysis of vasculature.
3. Modulation of released mast cell constituents (such as histamine and
interleukins) that could affect collagen metabolism.
4. Heating of collagen fibers and breaking of disulfide bonds with
subsequent collagen realignment.
Procedure
Patient characteristics
1. History of the scar or keloid in terms of age, evolution, and previous
treatments.
Preoperative
If topical anesthesia is desired, a lidocaine-containing cream or gel can be
applied to the treatment areas 3060 minutes before laser irradiation. Wear
protective goggles.
Intraoperative
1. Skin should be cleansed with soap and water to remove residual makeup,
powder, or creams. Flammable solutions, such as alcohol, should be
avoided in skin preparation.
2. Wet gauze may be used to protect hair-bearing areas during treatment
and to avoid unnecessary thermal injury to nontargeted skin.
3. A Test spot should be employed and if there is postoperative crusting
or vesiculation, the fluence applied on subsequent visits should be
decreased and retreatment postponed until the skin has completely
healed. The fluence and pulse duration can be adjusted if scar
proliferation continues despite laser irradiation. Generally speaking,
higher fluences and shorter pulse durations result in improved scar size
and pliability.

Dose: In general, hypertrophic scars and keloids are treated with
moderately low energy densities ranging from 6.0 to 7.5 J/cm2 (5 or 7
mm) or 4.5 to 5.5 J/cm2 (10 mm spot size). Pulse durations ranging from
0.45 to 1.5 milliseconds are commonly used.
Energy densities should be lowered by at least 0.5 J/cm2 in patients
with darker skin and for scars in delicate or thin-skinned locations
(e.g. eyelids, neck, chest). The entire surface of the scar is treated with
adjacent, nonoverlapping laser pulses.
4. Laser treatments are typically repeated at 68 week time intervals.
Postoperative
A topical healing ointment under a nonstick bandage can be applied for
the first few postoperative days to protect the skin. Treated areas should
be gently cleansed daily with water and mild soap. Strict sun avoidance
and photoprotection should be advocated between treatment sessions
to reduce the risk of pigment alteration. Topical bleaching agents (such as
hydroquinone or kojic acid) may be applied to hasten pigment resolution.
Pearls/Pitfalls
1. It is ideal to treat hypertrophic scars early, possibly within the rst few
months of appearance.
2. Previous treatments, such as cryotherapy, may cause increased brosis,
and thus adjustments of laser parameters and treatment sessions may
need to be made.
3. Location of the scar is also important to note. Dierickx et al. have found
that facial scars respond better to treatment. Nouri et al. have also found
that facial, shoulder, and arm scars respond better than those on the
anterior chest wall.
4. Laser treatment may be used alone or in combination therapy with
intralesional corticosteroids or 5-FU. Alster (2003) compared PDL
treatment alone with laser therapy combined with intralesional

corticosteroid treatment and found that both were similarly effective
with no signicant difference.
5. The use of concomitant intralesional corticosteroids or 5-fluorouracil
has been shown to provide additional benefit in proliferative scars.
Intralesional injections of corticosteroids (20 mg/mL triamcinolone)
are more easily delivered immediately after (rather than before) PDL
irradiation because the laser-irradiated scar becomes edematous
(making needle penetration easier). An additional consideration is
that when steroid injection is performed before laser irradiation the
skin blanches, rendering the skin a potentially less amenable target for
vascular-specific irradiation.
Results
The appearance of most hypertrophic scars will improve by approximately
50% after 2 treatments. Keloids often require additional treatment sessions to
achieve significant improvement, but some may prove unresponsive.
Side Effects
1. The most common side effect of treatment with the PDL is postoperative
purpura, which often persists for several days. Pulse durations shorter
than 6 milliseconds are almost certain to bruise the skin.
2. Edema of treated skin may also occur but usually subsides within 48
hours.
3. Hyperpigmentation has been reported with varying frequencies. If skin
darkening occurs, further laser treatment should be suspended until
resolution of the dyspigmentation has occurred in order to reduce the
risk of cutaneous melanin interference with laser energy penetration.
Fractional Laser
Nonablative fractional photothermolysis with near infrared 1,540 and
1,550 nm erbium-doped ber lasers is a promising new modality for the
treatment of hypertrophic scars. But these may help in textural improvement
and are not likely to affect the scar quality specially in keloids.
Thus, as stated above studies should be analyzed with respect to, redness
and height of the scar, improvement of pliability, and symptomatic relief of
pruritus as these constitutes substantial improvement.
NAFR (1,550 nm Erbium-doped Fiber Laser)

Niwa AB, et al. demonstrated signicant improvement after two to three
treatments, with improvement in pigmentation in all eight hypertrophic
scars evaluated. The dose used was from 35 to 50 mJ, and 8 to 10 passes were
applied withtreatmentlevels 68 . The ultimate evaluation was doen by the

quartile scoring system
Haedersdal M, et al. used a 1,540 nm nonablative fractional laser (Starlux,
Palomar Medical Technologies, Burlington, Mass., USA) in 17 burn scars (ve
with meshed split-thickness skin grafting) and showed signicant textural
improvement after three treatments.
AFR
Ablative fractional resurfacing lasers have been used in the treatment of
hypertrophic scars especially after burn cases (Haedersdal M).
Conclusion
One of the most common indications is in the treatment of burn scars
(Hultman CS, et al.). Restoration of form and function after burn injury
remains challenging, but traditional and emerging laser and light-based
technologies may offer new hope for patients with burn scars. Depending
upon the constellation of patient symptoms and functional deficits, treatment
of the burn scar involves a number of modalities, which may include massage
and moisturizing agents, pressure garments, silicone sheeting, topical and
intralesional steroids, and experimental therapies, such as interferon. The
three different laser and light-based technologies are now increasingly being
used in the management of burn scars.
i. Vascular-specific pulsed dye laser (PDL) therapy to reduce hyperemia
and hypertrophic scar formation.
ii. Ablative fractional CO2 laser resurfacing to help correct the abnormal
texture, thickness, and stiffness of the burn scar.
iii. Intense pulsed light (IPL) therapy to improve burn scar dyschromia and
alleviate chronic folliculitis.
Thus, it must be emphasized that the fractional laser may be one tool to help
in targeting an aspect of the scar and a multifaceted team approach is needed
for significant improvement.
Atrophic Scars
Laser used: Ablative lasers, nonablative lasers and fractional lasers.
Atrophic scars resulting from acne, chickenpox, trauma, can be treated with
laser therapy, though the results depend on numerous factors. Atrophic scars
are initially erythematous and with time become increasingly fibrotic and
hypopigmented. It is believed that atrophic scars result from inammatory
destruction of collagen with resultant dermal atrophy. Thus the tissue defect
has to be targeted and explains why methods like subcision are of little use in
chickenpox scars.
Newer ablative resurfacing in the spot mode is our favoured mode of
therapy. Nonablative resurfacing is considered safe but is not as effective as
ablative resurfacing. Fractional resurfacing offers the effectiveness of ablative

resurfacing and the safety of nonablative resurfacing.
1. Ablative Lasers
Though this has been detailed previously in the chapter of ablative lasers a
overview will be given here. The advantages of this modality include selective
and reproducibly vaporization of skin with improved operator control and
clinical efficacy. This is achieved by the novel devices including , high energyshort pulsed CO2 laser,the variable pulsed or dual-mode erbium YAG laser
and the combined-mode Erbium YAG/CO2 laser system.
Treatment Goal
Laser treatment of atrophic scars is aimed at reducing the depth of the scar
borders and stimulating neocollagenesis to fill in the depressions.
Mostly spot (or local) vaporization of isolated scars is used as full face
resurfacing is not practiced nowadays.
Procedure
Preoperative: Various anesthetic options can be employed, though for spot
ablation local anesthesia is used.
Intraoperative: The CO2 laser is generally used at fluences of 250 to 350 mJ
to ablate the epidermis in a single pass. Short-pulsed Er:YAG lasers that are
operated at 5 to 15 J/cm2 often require several passes to result in a similar
depth of penetration as CO2, whereas longer-pulsed Er:YAG systems can be
operated at higher fluences (22.5 J/cm2) to achieve comparable results in a
single pass.
Though the details have been discussed previously in the chapter of
Ablative Lasers, the basic steps are as follows:
1. Remove the epidermis over the scar (12 passes).
2. Focus around and over the scar shoulder and ablate it carefully to the
level of the base of the scar.
3. Give a pass over the center of the scar.
Postoperative: Postoperative erythema typically lasts several weeks after
ablative laser treatment.
Hyperpigmentation is transient and generally appears 34 weeks after
treatment. Its resolution can be hastened with the use of topical bleaching
agents.
Pearls
Ablative Er:YAG lasers may be the preferred treatment for mildly atrophic
scars, whereas ablative CO2 lasers may be preferable for more extensive
scarring. But, it is our view that a dual mode Er:YAG can achieve results
comparable to that of CO2.
2. Nonablative Lasers
As a consequence of the side effects and prolonged postoperative recovery
associated with ablative laser treatment, nonablative lasers were subsequently
developed to provide a noninvasive option for atrophic scar revision. But
it must be emphasized that the results are slower and less dramatic than
ablative lasers.
Devices and Lasers
1,064 nm Q-switched Nd:YAG laser /1,064 nm Long pulse Nd:YAG laser

1,320 Nd:YAG laser
1,540-nm erbium-doped phosphate glass laser (Er:Glass)
585 nm PDL and Intense pulse light system.
Although, protocols vary, treatments are generally performed at monthly
intervals for three consecutive months. Best results are observable 34
months after the last treatment.
Mode of Action
These devices deliver concomitant epidermal surface cooling with deeply
penetrating infrared wave-lengths that target tissue water and stimulate
collagen production via controlled dermal heating without epidermal
disruption.
It is possible that the absorption of the 1,064 nm wavelength by the blood
vessels in the scar may lead to either conduction to the surrounding dermis
to alter the brotic collagen within the scar or to signicant ischemia within
the laser-treated tissue to affect collagen or release collagenase.
Results
A series of 35 treatments are typically performed on a monthly basis, with
optimal clinical efficacy appreciated several (36) months after the final laser
treatment session. Sustained clinical improvement of scars by 40 to 50% has
been observed after the series of treatments. The low side-effect profile of
these nonablative systems (limited to local erythema and edema and, rarely,
vesiculation or herpes simplex reactivation) compensates for their reduced
clinical efficacy (relative to ablative lasers).
Conclusion
The results of the nonablative resurfacing depend on the patients own woundhealing capacities and, as stated before, will not equal those obtainable with
ablative treatments.
3. Fractional Lasers
Though this has been discussed in detail previously, our focus is primarily
on nonacne scars, namely, chickenpox and smallpox scars. As the thermal
coagulation required for ameliorating the tissue defect is more than what is
required for acne scars, the dose settings have to be more aggressive than
normal, which can be a issue as the side effects are also proportionately more.
Procedure
Preoperative
The ideal patient for fractional laser skin resurfacing has a fair complexion
(skin phototype I, II, or III), but darker skin tones (IVVI) can also be treated.
Sun exposure should be avoided prior to treatment in order to decrease
the risk of postoperative dyspigmentation.
For patients with a strong history of herpes labialis, prophylactic oral
antiviral medications should be considered when treating the perioral skin.
Reactivation of prior herpes simplex infection can occur despite absence of
an external wound, due to the intense dermal heat produced by the laser.
Intraoperative
1. The treatment areas should be cleansed of debris (including dirt,
makeup, and powder) using a mild cleanser and 70% alcohol.
2. A topical anesthetic cream is applied to the treatment sites for 60 minutes
before treatment.
3. NAFR can be done by using a dose setting of 4060 mJ ( maximum 70 mJ;
total 35 kJ)
Retreatments with gradually higher fluences should be performed
at 4-week intervals until patients are satisfied with clinical outcomes
(typically 35 sessions are necessary to produce substantial clinical
improvement).
4. AFR require 12 sessions
Fraxel repair: 20100 mJ with treatment densities of 6001600 MTZ/cm2.
Lumenis system (Total Fx): (Deep FX: 1525 mJ, active FX: 80125 mJ) and
densities (Deep FX: 1015%, active RX: 13%) depending on the severity of
scarring.
Postoperative
1. Patients who receive NAFR treatment should use a mild cleanser and
moisturizer several times daily for the first few days after each treatment
session (or as long as bronzing/xerosis is apparent).
2. Sun exposure should be avoided during this time.
Conclusion
Both ablative and nonablative fractionated lasers can be used and can help
to resolve both textural and pigmentary changes. The latter is important as

Table 11.2 Dose parameters for scar treatment for lasers
Condition
Laser
Settings
Hypertrophic
scars
585 595 nm PDL
6.07.5 J/cm2 (7 mm spot)

or 4.55.5 J/cm2 (10 mm spot) 1.53 ms
CO2 (10600 nm)
1 pass, 300 mJ, 60 watts,

5 J/cm2
Er:YAG (2940 nm)
23 passes, 5 mm spot
size, 515 J/cm2
Fractional CO2
DeepFXTM: thick, stiff scar,: density of

15%, frequency 600Hz, 12.517.5 mJ per
micropulse.
ActiveFXTM: Textural: frequency of 150 Hz,
7090 mJ per micropulse.
585 595 nm PDL
6.07.5 J/cm2 (7 mm spot)

4.55.5 J/cm2 (10 mm spot) 1.53 ms
CO2 (10600 nm)

5 J/cm2
Er:YAG (2940 nm)
23 passes, 5 mm spot
size, 515 J/cm2
Non-ablative
fractional
(1540/1550 nm)
15 mm handpiece,
3550 J/cm2
CO2 (10 600 nm)

5 J/cm2
Er:YAG (2940 nm)
2 3 passes, 5 mm spot
size, 5 15 J/cm2
Diode (1450 nm)
8 14 J/cm2 , 250 ms, 6 mm

spot size
Nd:YAG (1320 nm)
18 J/cm2 , 200 s, 6 mm
spot size
Keloids
Atrophic scars
(surgical or
trauma)
Box 11.1
Principles of laser therapy for scars
1. Keloids may be responsive only in the early stage. In late stage once the keloid becomes
firm and hard the PDL is not very useful. Even though various other lasers have been tried
the results are not satisfactory.
2. Hypertrophic Scars are easy to treat. A combination of PDL followed by Fractional CO2 can
be used.
3. Atrophic scars are best treated by an ablative laser. Nonablative NIR lasers and fractional
lasers are slower in action and incomplete in results.
4. Traditional medical therapies can be combined with lasers (Waibel JS, et al.)
with most ablative treatments hypopigmentation and even depigmentation

is seen.
Prescars
Treatment of potential scars with lasers is a relatively new concept that is
gaining in popularity. Two different approaches for scar prevention within
prescars have been outlined. Wound edges can be vaporized with either a
CO2 or an Er:YAG laser before primary surgical closure to enhance ultimate
cosmesis. Alternatively, a 585 nm PDL system can be used to treat surgical
sites, traumatic wounds or ulcerations to improve the quality of scarring and
prevent excessive scar formation.
Conclusion
Though lasers are now being used increasingly for treating scars, it must be
emphasized that they are one of the many tools that can be adopted. Except
for atrophic scars in most other indications, conventional modalities like IL
steroids/FU can and should be combined with lasers. The cost, time, and
effort required for results with lasers, do not justify their use in all cases.
In burn cases the use of PDL fractional lasers can be at best an adjunct
to traditional modes of therapy. Thus, we favor using laser in additions to
standard modalities.
The issue of dermal fillers in the area to be treated is important. Studies have
been done to determine the effect of different laser devices on skin previously
treated with hyaluronic acid llers (Farkas JP). Although the injected material
was unaffected by the nonablative laser and intense pulsed light treatments,
deeper laser treatments did demonstrate laser-ller interaction. The effect
of this interaction is not yet known. Also, newer ablative and nonablative
fractional lasers have the ability to penetrate deep into the dermis and, again,
the effects this may have on the llers is not yet known. Thus, care must be
taken when planning to use lasers in combination with soft tissue llers for
the treatment of scars.
A few principles are given in the Box 11.1, and a guide to dosimetry is
given in Table 11.2 which can help guide the clinician to plan a therapeutic
intervention.
Bibliography
1. Alster T, Zaulyanov L. Laser scar revision: a review. Dermatol Surg. 2007
2. Alster T. Laser scar revision: comparison study of 585-nm pulsed dye laser with
and without intralesional corticosteroids. Dermatol Surg. 2003;29(1):25-9.
3. Brewin MP, Lister TS. Prevention or treatment of hypertrophic burn scarring:
A review of when and how to treat with the Pulsed Dye Laser. Burns. 2014; pii:
S0305-4179(13)00442-7.

treatment for hypertrophic scars: comparison between Er:YAG and CO2
fractionallasers. J Dermatolog Treat. 2014;25(4):299-303.
5. Dierickx C, Goldman MP, Fitzpatrick RE. Laser treatment of erythematous/
hypertrophic and pigmented scars in 26 patients. Plast Reconstr Surg.
1995;95(1):84-90.
6. Haedersdal M, Moreau KE, et al. Fractional nonablative 1540 nm laser
resurfacing for thermal burn scars: a randomized controlled trial. Lasers Surg
Med. 2009;41(3):18995.
7. Haedersdal M. Fractional ablative CO2 laser resurfacing improves a thermal burn
scar. J Eur Acad Dermatol Venereol. 2009;23(11):13401.
8. Hultman CS , Edkins RE, Lee CN, Calvert CT, Cairns BA. Shine on: Review
ofLaser- and Light-Based Therapies for the Treatment of Burn Scars. Dermatol
Res Pract. 2012;2012:243651. doi: 10.1155/2012/243651.
9. Khatri KA, Mahoney DL, McCartney MJ. Laser scar revision: A review. J Cosmet
Laser Ther. 2011;13(2):54-62.
10. Mamalis AD, Lev-Tov H, Nguyen DH, Jagdeo JR. Laser and light-based treatment
of Keloids - a review. J Eur Acad Dermatol Venereol. 2013; doi: 10.1111/jdv.12253.
11. Niwa AB, Mello AP, et al. Fractional photothermolysis for the treatment
of hypertrophic scars: clinical experience of eight cases. Dermatol Surg.
2009;35(5):7737.
12. Nouri K, Jimenez GP, Harrison-Balestra C, et al. 585 nm pulsed dye laser in the
treatment of surgical scars starting on the suture removal day. Dermatol Surg.
2003;29:65-73.
13. Ud-Din S, Bayat A. Strategic management of keloid disease in ethnic skin: a
structured approach supported by the emerging literature. Br J Dermatol. 2013
Oct;169 Suppl 3:71-81.
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2005;13(2):325-31, vii. Review
Striae Distensae
Striae distensae or stretch marks are a common skin abnormality affecting
both sexes and all races. These lesions usually evolve through various stages
which are important to recognise before attempting any intervention
Acute: The striae appear red or violaceous and are referred to as striae rubra.
During this stage, they may be raised and often irritated.
Chronic: Here the striae become white, atrophied, and depressed. At this
stage, they are referred to as striae alba.
Role of Laser Treatment

Although striae are a common cause of concern, highly effective, low-risk
treatment modalities are lacking. These lesions are notoriously hard to treat.
Many treatments have been tried and tested. Topical treatment with tretinoin
cream 0.05%, l-ascorbic acid, and 20% glycolic acid have been shown to
improve the clinical appearance of striae alba, and tretinoin 0.1% cream has
been proven to improve the redness as well as length/width of striae rubra.
However, none of these treatments have been proven to increase collagen
or elastin production within the lesions. Ultraviolet (UV) B phototherapy has
been used to improve the hypopigmentation observed in striae alba, but it
does not correct the lesions atrophy
Lasers Used
The principles of therapy are akin to those given under the section on scars ,
thus newer lesions responding much better than old ones.
The laser used include flash-pumped 585 nm pulse dye laser, intense
pulsed light, 308-nm excimer laser, nonablative 1,450 nm diode laser,
radiofrequency device, 1,064 nm Nd:YAG laser, nonablative fractional
CO2resurfacing.
The basic principles are (Fig. 11.1) photothermolysis, and ablative fractional
1. Early stages (Rubra): 585 and 595 nm PDLs.
2. Late Stages : (Alba) use subsurface lasers and fractional lasers.
3. Pigmentary alteration: excimer laser.
4. Lasers should demonstate both clinical improvement in depth and
width and histological improvement with increase in the numbers of
collagen and elastin fibers (Fig. 11.2).
PDL: Should be used in striae rubra. In pigmented skin lower fluencies can
lead to hyperpigmentation. One or two treatment sessions are necessary.
Fractional Lasers
All the available technologies have been used including Er:Glass laser (1,550
nm), 1540 nm, Er:YAG and CO2 . Fractional photothermolysis creates multiple
noncontiguous zones of thermal damage in the epidermis and dermis,
sparing the tissue surrounding the wound. This in turn stimulates epidermal
Fig. 11.1: Overview of lasers and light devices for treating striae. Note that three
aspects have to be treated the width, depth and color of the striae
Pretreatment shows a thin epidermis while the post-treatment image shows an

increase in the thickness of the epidermis with an increase collagen and elastin
Figs 11.2A and B: A depiction of the histological effect of lasers on striae distensae
turnover and dermal collagen remodeling, which results in improvement of a

variety of scar types. As all fractional lasers have water as a chromophore they
are safe and we prefer using the 1540 nm as it has a relatively less absorption
spectrum for water and thus can lead to more collagen remodelling.
Dose: Use a low dose, high density setting spaced at 46 weeks.
(Example:Lux Palomar. Treatment parameters included two to three passes
with the 1540 nmlaser, with energy settings from 35 to 55 mJ/mb with the
10mm optical tip or 1214 mJ/mb with the 15 mm optical tip).
Comparison
As the depth of the pathology is in the upper dermis, as expected little
difference is seen between NAFR and AFR (Yang YJ).
Other Devices
IPL (590 nm), fractional RF and platelet rich plasma have also been tried.
Conclusion
Its the authors opinion that the result with most devices has rarely been
compared with a placebo group and there is a good chance that the patients
may have spontaneous remission. If an intervention is desired any fractional
device would suffice, with no advantage of ARR over NAFR.
Conservative fluencies should be used to ensure a mid dermis depth .As
the condition is akin to a atrophic scar a 30% decrease in fluence can be used
of the conventional settings for acne scars.
Do not hope for more than a 50% improvement. Proof of cure is histological
and that is rarely done in most studies.
Bibliography
1. Al-Dhalimi MA, Abo Nasyria AA. A comparative study of the effectiveness of
intense pulsed light wavelengths (650 nm vs 590 nm) in the treatment of striae
distensae. J Cosmet Laser Ther. 2013;15(3):120-5.
2. de Angelis F, Kolesnikova L, Renato F, Liguori G. Fractional nonablative 1540 nm
laser treatment of striae distensae in Fitzpatrick skin types II to IV:clinical and
histological results. Aesthet Surg J. 2011;31(4):411-9.
3. Gauglitz GG, Reinholz M, Kaudewitz P, Schauber J, Ruzicka T. Treatment of striae
distensae using an ablative Erbium: YAG fractional laser versus a 585-nm pulseddye laser. J Cosmet Laser Ther. 2013 Nov 18.
4. Jimnez GP, Flores F, Berman B, Gunja-Smith Z. Treatment of striae rubra and
striae alba with the 585-nm pulsed-dye laser. Dermatol Surg. 2003;29(4):362-5.
5. Suh DH, Lee SJ, Lee JH, Kim HJ, Shin MK, Song KY. Treatment of striae distensae
combined enhanced penetration platelet-rich plasma and ultrasound after
plasma fractional radiofrequency. J Cosmet Laser Ther. 2012;14(6):272-6.
6. Yang YJ, Lee GY. Treatment of Striae Distensae with Nonablative Fractional
Laser versus Ablative CO2 Fractional Laser: A Randomized Controlled Trial. Ann
Dermatol. 2011;23(4):481-9.
Section
Practical Aspects and

Advances
Chapter
12
Miscellaneous Laser
Responsive Disorders
Kabir Sardana
Introduction
There are numerous indications for lasers. Most of them are not approved
indications as yet, but considering the liberal US FDA approvals, it is likely
that they will be listed soon. We will give a brief overview of them and for sake
on convenience are listing them alphabetically.
Some of the indications like excimer light therapy for psoriasis and vitiligo
are approved, but it is the authors opinion based on objective evaluation of
studies that in tropical country with a high ambient UV flux, conventional
phototherapy is a cost effective option with equal site specific efficacy.
Other indication like the lasers for onychomycosis and hair growth are again
approved but very few RCT have been published. However, as these devices
are increasingly being used in practice an overview will nevertheless be given.
Acne
Light-based therapies are an attractive alternative acne therapy because as
they potentially offer more rapid onset and better patient compliance with
a low incidence of adverse events. However, optimal treatment methods
and the relative efcacy of light-based therapies as compared to traditional
therapies remain unclear. Light-based acne therapies are generally thought
to act via reducing Propionibacterium acnes proliferation or by targeting the
sebaceous gland to reduce sebum production; however, other mechanisms
may exist (Table 12.1).
Mode of Action
Propionibacterium acnes produces endogenous porphyrins that are
photoactivated, thus producing singlet oxygen species and free radicals that
may result in bacterial destruction.
Blue light results in the most pronounced photoactivation of endogenous
porphyrins. However, its clinical efcacy is limited by a shallow depth of
penetration. Combined blue and red light and photopneumatic therapy are

Table 12.1 Summary of devices that have a role in acne therapy
Inhibits P. acnes
Inhibits sebaceous gland
Inhibits sebaceous gland

and P. acnes
Blue and red light
1,320-nm
Nd:YAG laser
Photodynamic
therapy
IPL
1,450-nm
diode laser
Photopneumatic
therapy
1,540-nm
erbium:glass
laser
532-nm KTP laser

585/595-nm PDL
among the potentially promising therapies for acne that are believed to work,
at least in part, by targeting P. acnes.
Infrared wavelength lasers are often able to treat acne by causing
sebaceous gland alterations while preserving epidermal integrity. Variable
clinical responses have been observed with the 1,450-nm diode, 1,320-nm
neodymium:yttrium aluminum garnet, and 1,540-nm erbium:glass lasers
that target sebaceous glands. Our own experience with the Er:Glass (Lux
Palomar) has been that there is a certain degree of improvement of acne, but
this cannot be a justification of using it for acne. A recent study has also found
that fractional RF can help ameliorate active acne.
Photodynamic therapy (PDT) is potentially an effective light-based acne
therapy and may cause photodestruction of both P. acnes and sebaceous
glands. The optimal photosensitizer, light source, and therapeutic protocol
for PDT as a treatment for acne is unknown. However, noncoherent yellowred light has shown particular promise in some studies.
Summary
Though the study design of many clinical trials in this area make it impossible
to draw rm conclusions at this time, there is considerable evidence that
light-based therapies that act via photodestruction of P. acnes may be capable
of clinically improving acne. As light-based therapies are well tolerated and
have a low incidence of adverse events they may be used as an adjunct to
medical therapy.
Bibliography
1. Bogle MA, Dover JS, Arndt KA, et al. Evaluation of the 1,540-nm erbium:glass
laser in the treatment of inammatory facial acne. Dermatol Surg. 2007;33:810-7.
Miscellaneous Laser Responsive Disorders 381

2. Clark C, Bryden A, Dawe R, et al. Topical 5-aminolaevulinic acid photodynamic
therapy for cutaneous lesions: outcome and comparison of light sources.
Photodermatol Photoimmunol Photomed. 2003;19:134-41.
3. Lee KR, Lee EG, Lee HJ, Yoon MS. Assessment of treatment efficacy and
sebosuppressive effect of fractional radiofrequency microneedle on acne
vulgaris. Lasers Surg Med. 2013;45(10):639-47.
Benign tumors and Cysts

Though most of these lesions have been discussed in the chapter on ablative
lasers, a few uncommon indications are discussed here.
Epithelioma Adenoides Cysticum (Trichoepithelioma)

This condition is characterized by small, colorless papules that are located
mainly on nasolabial folds. Histologically they are hair follicle tumors
(trichoepitheliomas).
There are reports about successful treatment with the argon and CO2
lasers in individual cases. Recurrences depend on ablation depth and are
part of the nature of the disease (Sajben FP, et al).
Fibrous Papule of the Nose

These lesions are variously described as a broma or a regressive brosed
nevus. These lesions, which occur mostly isolated on the tip of the nose, are
essentially a cosmetic issue. Before laser therapy was introduced, excisions
and cauterization were the therapy options.
Due to the brous structure, ablation with the erbium:YAG or pulsed CO2
is an excellent choice.
The pulsed dye laser and the argon laser can also be considered as a
therapy option.
Koenen Tumors
Laser vaporization of Koenen tumors with a CO2 laser proved to be similar to
conventional surgical techniques in terms of cosmetic satisfaction. There are
two advantages though of using this lasers, first is the lack of bleeding and
second short operating time with excellent cosmetic and functional outcome.
Neurobromas
Treatment of neurobromas can be done effectively with the continuous wave
CO2 laser. After opening the epidermis, the neurobroma can be pressed out
and ablated. Removal should always be done completely down to the base to
prevent quick recurrence. (Figs 12.1A to E).
Figs 12.1A to E: (A) A neurofibroma on the side of the nose; (B) Local anesthesia is
given; (C) The Er:YAG (dermablate) is used to first abate the epidermis (7 J/cm2, 2 Hz);
(D) The Er:YAG ablation is continued till bleeding occurs signifying lower papillary
dermis. After this the pulsed CO2 is used to destroy the base; (E) Post-treatment
photograph showing complete healing of the lesion
Kardorff has published case reports about successful therapy of

neurobromas using the erbium: YAG laser in combination with surgical
excision.
Seborrheic Keratoses
Seborrheic keratoses are common benign, epidermal neoplasms that are very
variable in number, size, and color. There are numerous methods of removal
including electrofulguration.
Among the lasers, this author favors the use of the Er:YAG as it ensures an
accurate depth of penetration and excellent healing. A dose of 35 J/cm2 at
2 Hz gives rapid results (Dmovsek-Olup B). A single laser impulse is adequate
for most lesions. Some wipe the area with normal saline, which helps to
visualize the dermis, though it is better to leave the residue as it affords a
biological healing and sheds-off in 3-5 days. A controlled superpulsed CO2 is
another option (Fitzpatrick RE).
The Q-switched ruby or neodymium (Nd):YAG lasers can also be used
with good results for the treatment of at pigmented seborrheic keratoses.
The results depend on the thickness of the lesions, but one or two treatment
sessions suffice in most cases.
Viral Disorders
Though most viral disorders by nature are self-limiting with the most
consistent results being mediated by immune modulation, destructive
methods are often used, where lasers provide the best trade off between
efficacy and side effects.
Lasers Used
The CO2 laser light (wavelength of 10,600 nm) is mainly absorbed by water
and enables vaporization of tissue of any kind. Because a CO2 laser creates
temperatures of 200300C, the treatment is painful and requires some type
of anesthesia stronger than an eutectic mixture of local anesthetics (2.5%
lidocaine and 2.5% prilocaine emulsion in an oil-in-water base). Therefore,
most clinicians feel that for the treatment of viral infections, this type of laser
may be considered too invasive (Table 12.2).
The most commonly used laser though is the FPDL, which emits light in the
yellow-orange part of the visible light spectrum at 585 or 595 nm (Kauvar ANB).
When turned against skin, this light is best absorbed by hemoglobin and
oxyhemoglobin and is therefore used for the treatment of vascular lesions.
With very short pulses (0.45 ms) purpura develops within minutes in the
treated areas and needs 1014 days to resolve as macrophages digest damaged
material and blood residua. The yellow-orange light of this particular laser is
designed to destroy supercial blood vessels.

Table 12.2 Use of PDL lasers in viral disorders
Molluscum contagiosum
Dose
Pulse duration
No. of session
67 J/cm2
0.45 ms
1-2
Common warts
Dose
Pulse duration
No. of session
812 J/cm2
0.451.5 ms
18
Genital warts
Dose
Pulse duration
No. of session
67 J/cm2
0.45 ms
15
In viral warts the concept is to destroy the warts energy supply and
supposedly induce their regress, although a number of studies using the
FPDL and the same treatment parameters offer controversial results (Kopera
D). Other than transient purpura, side effects from FPDL treatment of viral
infections of the skin, when 0.45-ms pulses are used, are rare. They include
postlesional hyperpigmentation, blistering, and sometimes scarring.
Treatment for molluscum contagiosum must be individualized. Some
treatments may be painful and would not be the rst choice for children.
Other treatments are not painful but require diligence over a long period of
time. Sometimes, the best treatment is reassurance that the lesions are selflimited. Most would prefer curettage, cryosurgery, toxic or irritating topical
agents (e.g. cantharidin, uorouracil (5-FU), tretinoin, adapalene, salicylic
acid), and immunomodulating topical imiquimod. Lasers in our view are
a rapid method of therapy for molluscum. Apart from the CO2 laser, the
ashlamp-pumped pulsed dye laser (FPDL) can be used.
This author has treated numerous cases of molluscun contagiosum and it
provides a rapid, fast method of treatment, with a mode of action that combines
the best of extirpation and TCA/KOH, which is more cumbersome. Also the
high temperature can effectively kill the virus. A single spot mode in a dose of
0.52 W, with a pulse duration 10 ms is sufficient.
Inflammatory Disorders
Angiolymphoid Hyperplasia with Eosinophilia (ALHE)
The treatment of ALHE is known to be difcult. Intralesional corticosteroids,
surgical excision, and lasers are the most frequently used therapies, although
none of them is uniformly effective in all cases. Other options reviewed in
the literature are topical or oral corticosteroids, cryotherapy, oral retinoids,
imiquimod, tacrolimus, bleomycin, and INFA-2a.
Laser
Laser therapy can be a useful tool, especially for challenging locations in
which surgery cannot be performed. The most frequently used lasers to treat
ALHE are those targeting oxyhemoglobin. The use of the argon laser (484514
nm) was rst reported in 1988 but its long pulse duration lead to nonselective
damage and scarring. There are several reports about the use of pulsed dye
lasers (PDLs) for ALHE; most of them are single case reports in which complete
remission has been observed. Longer wavelength PDL (595 nm) seems
to be slightly more effective because it enables deeper tissue penetration
(around 2.5 mm). The common setting used are 585 nm, 710 mm, (57.5
J/cm2), 0.45 ms (Lertzman BH). But it must be appreciated that the results
may require up to 7 sessions and are not complete except while using the
595 nm (Angel CA).
Other lasers used include (Nd:YAG) laser has been reported, using a 6-mm
round spot size with two pulses of 7 ms duration with a 20-ms interpulse
delay and a uence of 100150 J/cm2. A copper vapor laser (CVL) was used
for the treatment of ALHE in one patient. CVLs emit yellow light (similar to
PDLs) of 578 nm. The pulse duration is 20 ms, with a pulse repetition rate of
15,000 cycles.
Because the carbon dioxide (CO2) laser is an ablative laser that targets
water, it is less selective than vascular lasers. But we prefer this as it has the
advantage of ablation with coagulation and is immeasurably cheaper than
PDL and millisecond pulsed Nd:YAG lasers (Kaur T). Though there are no
reports of the Er:YAG as it has a poor cogulative profile a dual mode Er:YAG
may be used.
Darier Disease
This genetic condition has been treated by lasers, though chances of
recurrence are there unless post-therapy histological confirmation can be
done.
Lasers Used
The carbon dioxide laser was successfully used to destroy recalcitrant
plaques in two patients with Darier disease by McElroy et al. with signicant
improvement and recurrence in only one treatment site. The same laser was
used by Minsue Chen et al. to treat a patient with lesions involving 40% of
total body area. The authors used a 3-mm spot and energies ranging from 10
to 40 W in two passes with tumescent local anesthesia, without recurrence at
2 years of follow-up. Nevertheless, the risk of scarring with a carbon dioxide
laser increases with the depth of treatment and the thermal damage.
Beier et al. treated two patients with an erbium Er:YAG laser (2,940 nm)
under local anesthesia with the painting technique and with an overlap
of 30%. The treatment endpoint was the exposure of the papillary dermis
including a margin of adjacent normal skin, using up to seven stacked pulses,
a spot size of 1.6 mm and uences of 58.5 J/cm2. No recurrences and/or
scarring were observed in the two patients in a follow-up of 20 months. Both
patients had remission of the pruritus; post-treatment hypopigmentation
was observed in the cubital and popliteal area of one patient and a few spots
with the other patient. Post-treatment biopsies showed no signs of Dariers
disease in both patients.
It is this authors view that a combination of Er:YAG and CO2 is a better
option as the Er:YAG has a predictable depth and when the end point of
ablation is achieved a pass of CO2 can enable adequate coagulation.
Dermatomyositis
There have been some reports of poikilodermatous erythema and
telangiectasias of DM treated with pulsed dye lasers and argon lasers, with
good response (Yanagi T).
Lasers have also been used successfully to treat other connective tissue
diseases (Brauer 2014).
Eczema
In 2008, (Syed S) reported a pilot study showed that PDL treatment improves
localized areas of chronic eczema. Twelve children with localized chronic
eczema were treated with PDL (595 nm). After 2 and 6 weeks, a signicant
decrease in eczema severity score was seen for the PDL-treated areas
compared with the control areas. Treatment was well tolerated.
This may suggest that dermal vasculature plays an important role in
chronic eczema or that PDL treatment may have an effect on cutaneous
immunological activation (Woo PN).
Elastosis Perforans Serpiginosa

Treatment with pulsed carbon dioxide and Er:YAG laser techniques may
have been modestly helpful in patients with idiopathic EPS (Vestey JP). The
pulsed dye laser has appeared to be benecial in one reported case of EPS in
a patient with Down syndrome.
Granuloma Annulare (GA)

In 1988, a carbon dioxide laser was used with good results to treat GA. There
are reports of the use of PDL where the lesion was treated with three times,
initially and at months 5 and 13. After the rst session of treatment, signicant
attening and reduction of erythema were evident. After the second and third
treatments, further improvment was observed and long-term remission was
achieved (Sniezek PJ).
In 2008, Karsai et al. (Karsai S) reported a patient with disseminated GA

who was treated with fractional photothermolysis using a 1,440-nm Nd:YAG
laser. A complete remission was achieved after two treatment sessions.
A recent report describes the use of excimer laser (Bronfenbrener R),
though it is the authors opinion that the results of photochemoterapy are
better with almost 50% clearing on the PUVA with a 79% remission rate
(Browne F).
Granuloma Faciale (GF)

A variety of surgical procedures may be used in the management of GF:
surgical excision, dermabrasion, electrosurgery, cryotherapy, and different
types of lasers. Argon laser use was rst reported in 1988, resulting in
resolution of the clinical and microscopic abnormalities. The laser most
frequently used to treat GF has been the pulsed dye laser.
Hailey-Hailey Disease
Dermabrasion is also an option for refractory lesions, with clearance rates
as high as 83% but with hypertrophic scarring being observed. Similar to
the patients with Dariers disease, the use of the carbon dioxide laser to
vaporize the lesions has been described by several authors (Kartamaa M),
with the treatment endpoint being skin destruction reaching the follicular
infundibulum while sparing the adnexal glands to avoid hypertrophic
scarring.
Kartamaa et al. used a continuous carbon dioxide laser to treat six patients
with symmetrical lesions, leaving one side as an untreated controls. There
was improvement on the treatment side in ve patients, with hypertrophic
scarring occurring in the axilar area of the other patient. Christian et al.
reported one patient with refractory axillary lesions treated with three passes
of a carbon dioxide laser using a uence of 28 J/cm2; focal recurrences were
managed with a short dwell carbon dioxide laser with a uence of 15 J/cm2.
Complete resolution was observed in only one side.
Beier et al. treated two patients with an Er:YAG 2,940-nm laser under
local anesthesia with the painting technique. These patients had axillary and
groin lesions and the treatment parameters were as follows: 0.35 ms pulse
duration, up to 7 stacked pulses, 5 mm spot size, and 58.5 J/cm2 uence.
Complete remission was observed in one patient at 1 year of follow-up; in
the other patient lesion recurrence occurred at the edges and adjacent areas,
which were managed with an additional treatment.
Lichen Sclerosus
The rst line of therapy is potent topical corticosteroids, such as clotebatosol
propionate for at least 3 months, combined with emolliens.
Recalcitrant lesions can be treated with a carbon dioxide laser, as

published by Peterson et al. The carbon dioxide laser is an ablative option for
this pathology with a retrospective study of 50 patients showing that 80% of
the patients were disease free at a median follow-up of 14 years (Windahl). A
simple method is to use the pulsed mode or a repeat mode (34 W; 0.20 S) in
a defocused beam and vaporize the macroscopically altered area of the glans
penis. If there is a phimosis that can be also treated simultaneously.
The PDT has been tried in 12 females with vulvar lichen sclerosus where
a dose of 3070 mW/cm2 was used with a wavelength of 635 nm. Treatment
was well tolerated by eight patients and a marked improvement in pruritus
was observed in 10 women, which was maintained for a mean of 6 months.
It must be remembered that surgical treatment by circumcision can be
curative, if the disease is treated early when still localized. Once progression
to urethral involvement has occurred, treatment is much more difficult
and lasers should be reserved for the early stage before meatal stenosis has
occurred (Stewart L).
Lupus Erythematosus
Though laser therapy offers novel and often effective treatment for recalcitrant
cutaneous conditions in lupus erythematosus (LE) scleroderma, sarcoidosis,
and dermatomyositis the limited number of reports, with outdated
technologies and techniques makes it difficult to recommend this as a first
line therapy for CTD (Brauer JA).
The PDL is used in several vascular disorders, such as rosacea
telangiectasias or port wine stains. The wavelengths of 585 or 595 nm are
selectively absorbed by oxyhemoglobin and allow a selective destruction of
the vessel walls. The rationale for the therapeutic success of PDL in LE is the
growing evidence that endothelial cells play a major role in the inammatory
process and systemic manifestations in LE. The targeting of endothelial cells
in rheumatic diseases is now an important eld in the development of new
drugs (Szekanecz Z), and even classic drugs used in the treatment of LE, such
as chloroquine, have been shown to reduce skin lesions from LE partially
through inhibition of angiogenesis.
Published series of patients with LE lesions treated with a PDL (Raulin
C) showed signicant improvement of skin lesions, even in those patients
with the systemic form of the disease. The older series used a PDL with a
wavelength of 585 nm, achieving a clearance rate of 70% in nine patients.
Another application for lasers in the treatment of LE is the atrophic scars,
especially in DLE because this subtype frequently causes disguring and
cribriform scars. The carbon dioxide laser in continuous wave mode has been
used though this author favors the use of the Erbium:YAG laser, due to its
measured dose depth response and excellent healing after ablation.
But it must be remembered that LE may be aggravated by UV light though

there are no published reports of such an aggravation due to PDL, CO2, or
erbium:YAG lasers.
Necrobiosis Lipoidica
In 1999, Currie et al. described a case report of necrobiosis lipoidica (NL)
treated with a PDL. At low uences, minimal therapeutic effect was achieved,
and at higher uences skin breakdown occurred, so they concluded that
caution is required when attempting to treat NL with a laser.
Other therapies tried include photodynamic therapy (De Giorgi V).
Nodular Amyloidosis
A patient with a large scalp lesion of nodular primary LCA was treated
with a CO2 laser with excellent cosmetic results and minimal morbidity
(Truhan AP). In 1999, a case report of multiple nodules treated with a PDL
was described, with clinical improvement in the color, size, and friability
of nodules maintained for 6 months (Alster TS). Histologic examination
revealed decreased inammation and improvement in dermal collagen after
laser irradiation.
There are certain important issues to appreciate before using lasers for
this condition (Lesiak A). Firstly, the pathology is deep and the amyloid is
admixed with a proliferative vasculature with the result that most ablative
procedures encounter bleeding that is an issue while treating this condition
with lasers (Hamzavi I). Though a report of fractional ablative laser has been
published (Anitha B), the concomitant use of a topical steroid salicylic acid
ointment means that probably the fractional lasers helped to increase the
transcutaneous penetration of the steroid than acted alone.
Sarcoidosis
Laser therapy has been used mainly for lupus pernio, which is the most
characteristic lesion of cutaneous sarcoidosis. It has a predilection for acral
sites, most commonly the nose. The lesions are usually violaceous plaques
or nodules that can be disguring and can cause signicant psychological
morbidity.
Lasers Used
Pulsed dye laser (PDL) was rst used by Goodman et al. where a 75% improve
ment after two treatments was seen, but recurrence was observed after 6
months. Cliff et al. conrmed the PDLs effectiveness to clear lupus pernio
clinically and histologically, with no recurrence after 2 months.
The carbon dioxide laser remodeling and healing by secondary intention

have also been performed for lupus pernio. Six cases have been reported
(ODonoghue NB) with satisfactory aesthetic results and no recurrence
in most cases. Some use intralesional triamcinolone acetonide after laser
therapy (Stack Jr BC).
In addition, the 532-nm frequency-doubled Nd: YAG laser has been used
to treat lupus pernio with a complete remission after a 3-year follow-up
(Ekback M).
Scar sarcoidosis is characterized by erythema, inltration, and progressive
induration of a pre-existing scar. It can resemble hypertrophic scars or keloids.
Anecdotal use of a Q-switched ruby laser lead to a complete clearance of scar
sarcoidosis lesions (Grema H).
Successful treatment of this condition was also reported using a 595-nm
PDL. No recurrence was observed after 1 year of follow-up. Laser treatment
seems to be effective for isolated cases of cutaneous sarcoidosis. Nevertheless,
only few cases have been reported so far. (Brauer JA).
Conclusion
There are two issues with the use of lasers. Firstly in most cases the followup period has been short for a disease like sarcoidosis where recurrences
have been seen even after years of steroid therapy. Secondly there are cases
of aggravation of sarcoidosis with PDL therapy and CO2 laser. Thus lasers are
not to be used as a prefential treatment in sarcoidosis (Kormeili T)
Psoriasis
The benets of using the 308 nm excimer laser for psoriasis are wellestablished and it has been shown that the psoriatic lesions treated with the
excimer laser cleared with fewer treatments than narrow band UVB therapy.
Though a summary of the indications and advantages are given below, it
is this authors opinion that PUVA/sol is a reasonably effective option for
psoriasis, with a more pronounced immunomodulatory effect than excimer
laser.
Indications
Localized plaques that have not responded to medical therapy
Mild to moderate psoriasis
Type IIIV skin with limited disease to the scalp or exural areas.
Advantages
It spares the uninvolved skin from UV exposure
Remissions for up to 2 years have been seen in some patients
Laser therapy demonstrated efcacy at lower cumulative doses when

compared to conventional light therapy
Used for psoriatic lesions that occurs in the groin and axilla (inverse
psoriasis) and scalp
It can be used in all skin types.
Summary
The ultraviolet B (UVB) phototherapy is an effective treatment modality for
psoriasis. For patients with localized plaque-type lesions, 308-nm excimer
laser phototherapy offers rapidly delivered, targeted, high UVB doses,
while sparing adjacent healthy skin. A study by Mudigonda T compared the
advantages and disadvantages of the 308-nm xenon chloride (XeCI) UVB
excimer laser with nontargeted broadband UVB (BB-UVB), narrowband UVB
(NB-UVB), and psoralen plus UVA (PUVA) phototherapies.
Three prospective nonrandomized studies compared NB-UVB with
excimer laser phototherapy. No head-to-head studies were found for BBUVB or PUVA compared to excimer laser. Both the 308-nmexcimerlaser and
nontargeted phototherapies were found to effectively clear localizedpsoriasis.
Although it is proposed that excimer laser exclusively treats diseased skin
with better response rates, split-body trials revealed no differences. Longterm studies are necessary to compare the effects of high-doseexcimerlaser
regimens with nontargeted phototherapies.
Interestingly PUVA has not been compared with excimer laser and it is
quite likely that due to the more profound immunomodulatory effect and
depth of penetration, PUVA is probably superior in terms of efficacy and
relapse rates.
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laser superpulsed mode. Treatment of verruca vulgaris, seborrheic keratoses,
lentigines, and actinic cheilitis. Dermatol Surg Oncol. 1994;20:449-56.
15. Goodman MM, Alpern K. Treatment of lupus pernio with the ashlamp pulsed
dye laser. Lasers Surg Med. 1992;12:549-51.
16. Grema H, Greve B, Raulin C. Scar sarcoidosistreatment with the Q-switched
ruby laser. Lasers Surg Med. 2002;30:398-400.
17. Hamzavi I, Lui H. Excess tissue friability during CO2 laser vaporization of nodular
amyloidosis. Dermatol Surg. 1999;25(9):726-8.
18. Kardorff B. Neurobromatose Typ I (Morbus Recklinghausen): Kombinierte
Erbium:YAG-Laser- und Exzisionstherapie von kutanen Neurobromen. Derm.
1998;4:404-6.
19. Karsai S, Hammes S, Rtten A, Raulin C. Fractional photothermolysis for the
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20. Kartamaa M, Reitamo S. Familial benign chronic pemphigus (Hailey-Hailey
disease). Treatment with carbon dioxide laser vaporization. Arch Dermatol.
1992;128:646-8.
21. Kaur T, Sandhu K, Gupta S, Kanwar AJ, Kumar B. Treatment of angiolymphoid
hyperplasia with eosinophilia with the carbon dioxide laser. J Dermatolog Treat.
2004;15:328-30.
22. Kauvar ANB, McDaniel DH, Geronemus RG. Pulsed dye laser treatment of warts.
Arch Fam Med. 1995;4:1035-40.
23. Kopera D. Verrucae vulgares: ashlamp-pumped pulsed dye laser treatment in
134 patients. Int J Dermatol. 2003;42:905-8.
24. Kormeili T, Neel V, Moy RL. Cutaneous sarcoidosis at sites of previous lasersurgery.
Cutis. 2004;73(1):53-5.
25. Lertzman BH, McMeekin T, Gaspari AA. Pulsed dye laser treatment of
angiolymphoid hyperplasia with eosinophilia lesions. Arch Dermatol.
1997;133:920-1.
26. Lesiac A, Rakowski A, Brzezinska A, et al. Effective treatment of nodular
amyloidosis with carbon dioxide laser. J Cutan Med Surg. 2012;16(5):372-4.
27. McElroy JA, Mehregan DA, Roenigk RK. Carbon dioxide laser vaporization of
recalcitrant symptomatic plaques of Hailey-Hailey disease and Dariers disease.
J Am Acad Dermatol. 1990;23:893-7.

28. Minsue Chen T, Wanitphakdeedecha R, Nguyen TH. Carbon dioxide laser
ablation and adjunctive destruction for Darier-White disease (keratosis
follicularis). Dermatol Surg. 2008;34:1431-4.
29. Mudigonda T, Dabade TS, West CE, Feldman SR. Therapeutic modalities for
localized psoriasis: 308-nm UVB excimer laser versus nontargeted phototherapy.
Cutis. 2012;90(3):149-54.
30. ODonoghue NB, Barlow RJ. Laser remodelling of nodular nasal lupus pernio.
Clin Exp Dermatol. 2006;31:27-9.
31. Peterson CM, Lane JE, Ratz JL. Successful carbon dioxide laser therapy for
refractory anogenital lichen sclerosus. Dermatol Surg. 2004;30:1148-51.
32. Raulin C, Schmidt C, Hellwig S. Cutaneous lupus erythematosus-treatment with
pulsed dye laser. Br J Dermatol. 1999;141:1046-50.
33. Sajben FP, Ross EV. The use of the 1.0 mm handpiece in high energy, pulsed CO2
laser destruction of facial adnexal tumors. Dermatol Surg. 1999;25:41-4.
34. Sniezek PJ, DeBloom JR 2nd, Arpey CJ. Treatment of granuloma annulare with
the585 nm pulsed dye laser. Dermatol Surg. 2005;31(10):1370-3.
35. Stack Jr BC, Hall PJ, Goodman AL, Perez IR. CO2 laser excision of lupus pernio of
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36. Stewart L, McCammon K, Metro M, Virasoro R. SIU/ICUD Consultation
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37. Syed S, Weibel L, Kennedy H, Harper JI. A pilot study showing pulsed-dye
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Dermatol. 2008;33:243-8.
38. Sysa-Jedrzejowska A, Narbutt J. Effective treatment of nodular amyloidosis
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39. Szekanecz Z, Koch AE. Vascular involvement in rheumatic diseases: vascular
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Pigmentary Disorders
Vitiligo
Among the various forms of therapy for vitiligo, phototherapy is an important
intervention. Excimer laser and light system are basically a form of targeted
UVB therapy, which is an option for small areas recalcitrant to conventional

therapy.
Lasers Used
The 308-nm excimer laser and lamp have been used in dermatology since 1997.
These devices emit a wavelength in the UVB spectrum. The monochromatic
wavelength at 308 nm provides photobiological effects for those devices
that are theoretically superior compared with NB-UVB, especially for their
immunologic effects. In vitiligo, a more immediate requirement is the
migration and the proliferation of melanocytes where there seems to be no
advantage of the 308-nm and NB-UVB wavelengths (Casacci M et al).
The 308-nm excimer lamp is not strictly monochromatic and the beam of
light is not coherent and those systems are much less expensive than lasers.
The data concerning the treatment of vitiligo with the 308-nm excimer lamps
are much more limited compared with excimer lasers, but they seem to
provide a comparable rate of repigmentation (Shi Q et al).
The 632.8-nm heliumneon laser has also been tried for vitiligo, though
the data at present is limited.
Advantages
The uences to be used are low and the immediate side effects are limited
to erythema and rarely blisters (especially if sessions are repeated 3 times a
week). Also these devices allow treatment of areas that are usually difficult to
reach with UV cabins such as the folds, and they specifically target the affected
depigmented patches, preventing hyperpigmentation of the surrounding
skin.
Disadvantages
Only relatively small surfaces can be treated and most authors propose the
use of these devices for lesions affecting less than 10% of the total surface
body area.
Results
The clinical efcacy of the 308-nm excimer laser is well demonstrated. Overall,
2030% of the treated patches reach a satisfactory aesthetic result, that is, a
repigmentation of at least 75%. Those results appear superior to those usually
obtained with NB-UVB phototherapy but direct comparison data between
NB-UVB and 308-nm emitting devices are still very limited.
A study that has been published is a important lesson for clinicians
wishing to buy the excimer system in preference over NB-UVB. Verhaeghe
E studied the efficacy of 308-nm MEL versus localized 311-nm NB-UVB
in vitiligo patients. This prospective intrapatient placebo-controlled
randomized trial found that while 20% of the lesions treated with NB-UVB
achieved repigmentation scores above 50%, none of the lesions treated with
MEL achieved a repigmentation higher than 50% after 24 sessions. Thus,
localized 311-nm NB-UVB is more effective in the treatment of vitiligo and
an unbiased view reinforces the fact that it is better than the 308-nm excimer
lasers.
In India, where PUVA is practiced, it is the authors opinion in conjunction
with a recent study (Singh S) that probably with the abundant sunlight and
low risk of melanoma in our skin, the excimer laser cannot be universally
recommended especially for the larger population that cannot afford this
therapy.
Other Indications of Excimer Laser

They include postresurfacing leukoderma, leukoderma after laser tattoo
removal with a Q-switched neodymium:YAG laser, hypopigmented striae,
halo nevus and nevus depigmentosus.
Conclusion
Lasers for vitiligo reinforce certain principles for using lasers. Firstly, they
should be superior to conventional therapies, secondly the results should be
stable and long-term follow-up studies must be published. The safety profile
is a recurring theme, that is probably relevant in FST(I-III) but in darker skin
types this is not necessarily an issue.
Predictably, some of the advantages with conventional phototherapy
and PUVA are also seen with excimer lasers, like, the excellent results on
the face, with more than three-fourths of patients reaching at least 75%
repigmentation. But the system has not been and probably will not be able to
overcome the known issues with conventional phototherapy namely;
1. Lack of response on the extremities and the bony prominences.
2. Lack of stability of response, which is impossible to predict as longterm results have not been reported. In fact, one study reported no
repigmentation after 1 year of follow-up.
A summary of the use of this system is provided in Box 12.1.
Box 12.1 Overview of excimer laser light in vitiligo

Indication
Limited or localized lesions of vitiligo
Site
(most to least responsive)
Face, scalp/neck, genitals, trunk, extremities,

hands and feet, including bony prominences
Skin type
Fitzpatrick III or higher skin types

respond the best
Size
Small lesions respond more quickly
The development of the 308-nm excimer lamp is more recent and is

much cheaper and the results are comparable to excimer lasers. Le Duff F
et al. performed a prospective trial comparing the 308-nm excimer laser and
the 308-nm excimer lamp and conrmed that these two devices are equally
effective in repigmenting vitiligo patches.
Lasers and Melanocyte Grafting

Surgical approaches are recommended for segmental vitiligo or for localized
vitiligo that has been stable for more than 3 years. It is also a useful method for
congenital hypomelanosis, such as piebaldism, or for nevus depigmentosus.
The preparation of the recipient bed before grafting requires a homogeneous
epithelial removal.
Both the CO2 lasers (Kahn) and more recently, the erbium:yttrium
aluminum garnet (YAG) lasers (Pai GS) followed by epidermal skin grafts or
epidermal suspension grafts have been used. Such a method has also been
used in piebaldism (Guerra L). Recently, dermabrasion with erbium:YAG laser
followed by uorouracil applications before narrowband (NB) UVB therapy
was compared to NB UVB alone in 50 patients with symmetrical patches of
vitiligo (Anbar TS). A moderate to marked improvement was observed in
78.1% of the lesions treated with the combination protocol as compared with
23.4% of the lesions that have only received phototherapy. Pain and transient
hyperpigmentation was reported in the combination group. Those results
clearly need to be conrmed, but they suggest an interesting new approach
for treating vitiligo.
Our experience with this is restricted to the Er:YAG. This is set at a dose of
56 J/cm2 and multiple passes are made till pinpoint bleeding appears, which
is the end point. A study is underway comparing this with conventional
surgical grafting, thus this author cannot yet recommend it as a preferential
method for recipient site preparation (Figs 12.2 and 12.3).
Lasers for Inducing Leukoderma

Laser devices were rst used for depigmenting the residual pigmented areas
in generalized vitiligo. Permanent depigmentation is usually proposed for
people older than 40 years and after detailed information is given to the
patient. Monobenzylether of hydroquinone (MBEH) causes a permanent
depigmentation of the skin that has been used for generalized vitiligo.
Though some lasers have been used the evidence for their use and their
efficacy is limited. A short, retrospective study suggests that a Q-switched
ruby laser is as effective as MBEH (depigmentation was observed in 69%
of the subjects with both kinds of treatments) (Njoo MD). Of interest, a
repigmentation of treated areas was observed in 44% and 36% of the patients
treated with lasers and MEBH, respectively. Thus, patients should be informed
of the risk of repigmentation after both kinds of treatment.
Fig. 12.2: Two passes have been given with the Er:YAG laser. Note the loss of
epidermis and a faint erythema, which signifies the papillary dermis
Fig. 12.3: Pinpoint bleeding is the end point of the ablation
Isolated success has been reported in a patient with generalized vitiligo

who was treated with a Q-switched ruby laser, with no repigmentation
observed 1 year after the treatment (Kim YJ). More recently, a Q-switched
alexandrite laser has shown its efcacy in the depigmentation of one patient.
Again, no repigmentation was observed at follow-up after 1 year (Rao J). A
study from India (Majid I) used the Q-switeced 532 nm but the concomitant
use of MBEH with the laser can potentially influence the results.
Thus, depigmenting lasers seem to be an attractive alternative to MEBH
for depigmenting patients with generalized vitiligo but they should be
reserved for limited surfaces and they should not be proposed if depigmentation involves less than 50% of the affected area. In all the cases, patients
have to be clearly informed of the potential risk of later repigmentation and

photoprotection of the treated areas should be systematically prescribed.
More importantly if the Q-switched Nd:YAG is used the 532 nm is used in
preference to the 1,064 nm.
Bibliography
1. Anbar TS, Westerhof W, Abdel-Rahman AT, Ewis AA, El-Khayyat MA. Effect of
one session of ER:YAG laser ablation plus topical 5-Fluorouracil on the outcome
of short-term NB-UVB phototherapy in the treatment of non-segmental vitiligo:
a left-right comparative study. Photodermatol Photoimmunol Photomed.
2008;24:322-9.
2. Casacci M, Thomas P, Pacico A, Bonnevalle A, Paro Vidolin A, Leone G.
Comparison between 308-nm monochromatic excimer light and narrowband
UVB phototherapy (311313 nm) in the treatment of vitiligoa multicentre
controlled study. J Eur Acad Dermatol Venereol. 2007;21:956-63.
3. Guerra L, Primavera G, Raskovic D, Pellegrini G, Golisano O, Bondanza S, et al.
Permanent repigmentation of piebaldism by erbium:YAG laser and autologous
cultured epidermis. Br J Dermatol. 2004;150:715-21.
4. Kahn AM, Ostad A, Moy RL. Grafting following short-pulse carbon dioxide laser
de-epithelialization. Dermatol Surg. 1996;22:965-7; discussion 967-8.
5. Kim YJ, Chung BS, Choi KC. Depigmentation therapy with Q-switched ruby laser
after tanning in vitiligo universalis. Dermatol Surg. 2001;27:969-70.
6. Le Duff F, Fontas E, Giacchero D, Sillard L, Lacour JP, Ortonne JP, Passeron T. 308nm excimer lamp vs. 308-nm excimer laser for treating vitiligo: a randomized
study. Br J Dermatol. 2010;163(1):188-92.
7. Majid I, Imran S. Depigmentation therapy with Q-switched Nd: YAG laser in
universal vitiligo. J Cutan Aesthet Surg. 2013;6(2):93-6.
8. Njoo MD, Vodegel RM, Westerhof W. Depigmentation therapy in vitiligo
universalis with topical 4methoxyphenol and the Q-switched ruby laser. J Am
Acad Dermatol. 2000;42:760-9.
9. Pai GS, Vinod V, Joshi A. Efcacy of erbium YAG laser-assisted autologous
epidermal grafting in vitiligo. J Eur Acad Dermatol Venereol. 2002;16:604-6.
10. Rao J, Fitzpatrick RE. Use of the Q-switched 755-nm alexandrite laser to treat
recalcitrant pigment after depigmentation therapy for vitiligo. Dermatol Surg.
2004;30:1043-5.
11. Shi Q, Li K, Fu J, Wang Y, Ma C, Li Q, et al. Gao T. Comparison of the 308-nm
excimer laser with the 308-nm excimer lamp in the treatment of vitiligoa
randomized bilateral comparison study. Photodermatol Photoimmunol
Photomed. 2013;29(1):27-33.
12. Singh S, Khandpur S, Sharma VK, Ramam M. Comparison of efficacy and sideeffect profile of oral PUVA vs. oral PUVA sol in the treatment of vitiligo: a 36-week
prospective study. J Eur Acad Dermatol Venereol. 2013;27(11):1344-51.
13. Verhaeghe E, Lodewick E, van Geel N, Lambert J. Intrapatient comparison of 308nm monochromatic excimer light and localized narrow-band UVB phototherapy
in the treatment of vitiligo: a randomized controlled trial. Dermatology.
2011;223(4):343-8.
Hair Disorders
Though, lasers have been used for hair transplantation, we will largely focus
on the direct effect of lasers on hair growth.
Though lasers and light therapies for alopecia include 308 nm excimer
laser, fractional photothermolysis, and UV phototherapy, we will largely
focus on LLLT (Avci P).
It has long been known that red or near-infrared laser light promotes
tissue repair and regeneration and low-intensity light called low-level laser
therapy (LLLT) stimulates cellular activity (Schindl A). After the discovery of
lasers in the 1960s, there has been tremendous interest in using these laser
devices to treat various medical conditions. The most commonly used devices
have wave lengths in the range 5001,100 nm (the so-called optical window
of tissue) and they deliver uences of 110 J/cm 2 with a power density of
390 mW/cm2. LLLT has shown benecial effects for a variety of medical
conditions such as wound healing, nerve regeneration, joint pain relief,
stroke recovery, and the prevention and treatment of mucositis. Home-use
LLLT devices that emit low power coherent monochromatic red light have
been developed for various skin conditions, including hair growth.
Alopecia
The pathogenesis of alopecia depends on the type of hair loss. The genetic hair
loss, androgenetic alopecia is consequent to DHT, which binds to the nuclear
androgen receptor, which regulates gene expression. Disruption of epithelial
progenitor cell activation and cell proliferation due to abnormal androgen
signaling forms the essential pathophysiological component of this condi
tion which in turn leads to continuous miniaturization of sensitive terminal
hair follicles, and their conversion to vellus hair follicles. Although the exact
genes involved in hair loss are not clearly known, some of the proposed genes
responsible for hair growth are desmoglein, activin, epidermal growth factor
(EGF), broblast growth factor (FGF), lymphoid-enhancer factor-1 (LEF1), and sonic hedgehog. There are several other forms of hair loss such as
alopecia areata (AA), telogen efuvium (TE), and chemotherapy-induced
alopecia. AA is an autoimmune inammatory condition, which presents with
non-scarring alopecia.
While the conventional methods of therapy include topical minoxidil,
nasteride (males only), and surgical hair transplantation with LLLT having
received FDA approval. The HairMax LaserComb1 was approved by the US
Food and Drug Administration (FDA) and received 510 K clearance as a
safe therapy for the treatment of male AGA in 2007 and female AGA in 2011
(Wikramanayake TC). The other FDA approved devices include Sunetics,
Laser Hair Brush and Clinical unit, Revage 670 Laser (Chair unit) and Spencer
Forrest X5 (Handheld) Hair Laser. Recently a diode laser the X5 HairLaser has
been used. Though a sham device failure and resultant missing data from the
control group, are a negative aspect, the authors report a positive trend hair
growth, due to the chronic use of X5 hairlaser device (Blum K).
Basic Science of LLLT

There are a few mechanisms proposed for its action and are listed below.
1. Stimulates the mitochondrial transport chain
2. Enhances ATP production
3. Stimulates wound healing
4. Reduces inammation, improves neurologic damage, such as with
stroke improves musculoskeletal and joint pain.
The extension of this form of therapy to alopecia has an interesting
history. In the late 1960s, Endre Mester, a Hungarian physician, began a series
of experiments on the carcinogenic potential of lasers by using a low-power
ruby laser (694 nm) on mice. Mice were shaved as a part of the experimental
protocol. To Mesters surprise, the laser did not cause cancer but instead
improved hair growth around the shaved region on the animals back. This
was the rst demonstration of photobiostimulation with LLLT, and it
opened a new path in the eld of medicine.
This experimental fact was supported by a clinical phenomenon where an
increase in hair density, color or coarseness or a combination of these occurs
at or around sites treated for hair removal (Vlachos SP, Moreno-Arias G) and
is known as Paradoxical Hypertrichosis, the incidence of which varies from
0.6% to 10%.
A group of researchers also observed transformation of small vellus hairs
into larger terminal hairs upon low uence diode laser treatment and named
this phenomenon terminalization of vellus hair follicles (Bernstein EF).
Why this happens is yet unknown and has been explained by a sub
therapeutic heat generation, which induces follicular stem cell proliferation
and differentiation by increasing the level of heat shock proteins (HSPs) such
as HSP27, which plays a role in regulation of cell growth and differentiation.
Thus sub-therapeutic injury caused by the laser could also result in the release
of certain factors, which could potentially induce follicular angiogenesis and
affect the cell cycling.
Thus, laser phototherapy is assumed to stimulate anagen re-entry in
telogen hair follicles, prolong duration of anagen phase, increase rates of
proliferation in active anagen hair follicles and to prevent premature catagen
development.
Conclusion
A list of studies is mentioned in the Table 12.3. The results of all the devices
depend largely on the parameters used to assess them and long-term followup. However, more studies are needed to optimize treatment parameters

Table 12.3 Clinical studies of LLLT in Alopecia
Patients
Diagnosis
Device parameters
and treatment
regimen
Yamazaki
et al.,
2003
6 male and 9
female
patients
Alopecia
areata
Super LizerTM
pulsed linear
light, 6001,600 nm,
1.8W, 3 minutes/
week or every other
week
The patients
received additional
supplements
and medications
and were treated
until vellus hair
regrowth in at least
50% of the affected
area LLLT only
accelerates the
process of hair
regrowth in AA
patients
Satino et al.,
2003
28 male and 7
female
patients
Androgenetic
alopecia
HairMax LaserComb
655 nm, 510
minutes every other
day, for 6 months
Hair tensile
strength improved
in the vertex area
for males and
temporal area for
females.
Hair count
improved (for
temporal area:
55% in women,
74% in men, in
vertex area: 65% in
women, 120% in
men) with
vertex area in
males having the
best outcome
Kim et al.,
2007
24 male
patients
Androgenetic
alopecia
655 and 780 nm,

once a day for 10
minutes, for 14
weeks
Leavitt et al.,
2009
110 male
patients
HairMax LaserComb,
3 times/week for
15 minutes, for 26
weeks
Signicantly
greater increase in
mean terminal hair
density compared
to subjects in the
sham device group
Contd...
Contd...
Patients
Diagnosis
Device parameters
and treatment
regimen
Lanzafame
et al.,
2013
44 male
patients
Androgenetic
alopecia
Helmet
(TOPHAT655)
containing 21, 5 mW
lasers and 30 LEDs,
655 nm, 67.3 J/cm2
25 minutes every
other day, for 16
weeks
35% increase in
hair growth among
male AGA patients
Kim et al.,
2013
40 patients
Helmet type LLLT

device, 650 nm laser
with 630 and
660 nm LEDs, 92.15
mW/cm2,47.90 J/cm2
18 minutes/day, for
24 weeks
LLLT increased
hair
count and shaft
diameter, however,
blinded global
images did not
support these
observations
and determine long-term efcacy as well as safety of emerging LLLT

technologies. Most studies investigating effects of LLLT on hair growth have
used wavelengths that range from 635 to 650 nm, but as of today no study
has compared the effect of near-infrared wavelengths such as 810 nm, which
have deeper penetrating capacities, to red light. Moreover, further studies are
required to compare efcacy of different light sources (continuous vs. pulsed)
and methods of light delivery (laser versus LED).
While lasers are largely safe, there are certain overbearing concerns that
shroud the use of these devices.
1. There is still a paucity of peer-reviewed studies validating LLLT for hair
loss. It is unclear why so few studies exist, given the positive anecdotal
reports described above.
2. The treatment of alopecia has moved from the domain of dermatologists
to quacks, beauticians, homeopath and so called trichologists. While
we can appreciate the nuances of the etiology, this is lost on alternative
practitioners and patients. Thus, a detailed evaluation and biopsy with
its proper interpretation is needed where necessary. If LLLT is made
a home use device, which it largely is, there will be situations where
results will not be commiserate with the diagnosis. Who will protect
consumers from buying expensive items that may not be applicable or
aggressive enough for their type of hair loss?
But as trained dermatologists we should be open to the use of such
devices where other options have failed, so long as reproducible studies can
demonstrate their safety and efficacy.
Nail Disorders
The use of lasers for nail disorders is the hot new indication though it is
fraught with numerous issues.
The lasers used are, millisecond lasers, diode laser, Q-switched lasers,
PDT and UV light and recently, fractional lasers have (Lim EH).
Mode of Action of Lasers

It has been shown that a temperature of at least 55oC for 5 minutes is required
to kill dermatophytes in water suspension (Engelhardt-Zasada C). In vitro
studies have shown growth impairment of nail clippings or cell culture media
above 50C when heated with a 1,064 or 980 nm laser systems (Paasch U).
Conversely, other in vitro studies have shown no inhibition of fungal growth
with Nd:YAG laser treatment of T. rubrum (Hees H). Interestingly, the
germination of certain species of dermatophytes is accelerated at 40 degrees.
This may suggest a stimulatory effect at subtherapeutic temperatures.
The problem is that dermatophyte infections are comprised of both
hyphae and spores of which spores can be more difcult to eradicate. Also
at high temperatures there can be damage to normal collagen (>45 degrees)
and skin necrosis can be seen at 50oC. If laser and light-based devices act
through nonspecic bulk heating of dermatophytes, there is a high risk
of heating and destroying surrounding normal tissue while attempting to
eradicate dermatophytes. This would produce unacceptable side effects such
as ulceration, dyspigmentation, and scar. Thus, selective photothermolysis
of dermatophytes, while sparing surrounding skin structures, is preferable.
But conversely, a study by Carney C et al. where a submillisecond 1,064 nm
Nd:YAG laser (Laser Genesis, Cutera, Inc.) was used found that direct laser
irradiation with the 1,064 nm laser of fungal colonies on the potato dextrose
agar plate only peaked to temperatures of 40 degrees. Also the average
percent of disease involvement was not reported by the authors, but could
be calculated with the stated results to be about 33%. The improvement in
percent involvement however, did not correlate to clinical or mycologic cure.
Although, the in vitro study showed a fungicidal effect with heat, the results
did not translate to clinical effectiveness given the degree of temperature and
duration of heat required to obtain a fungicidal effect.
Laser Used
Currently, all of the FDA cleared lasers for the treatment of onychomycosis are
neodymium-doped yttrium-aluminum-garnet (Nd:YAG) lasers including:
Pinpointe TM FootLaser TM (Nuvolase, Inc., Chico, CA), GenesisPlus TM (Cutera,
Inc., Brisbane, CA), Q-Clear TM (Light Age, Inc., Somerset, NJ), CoolTouch
VARIA TM (CoolTouch, Inc., Roseville, CA), and JOULE ClearSense TM (Sciton,
Inc., Palo Alto, CA). But as has been discussed in chapter 13 regulatory
clearance of medical devices is based on substantial equivalence to a legally

marketed pre-existing device rather than on the basis of clinical trials data.
Therefore, one cannot infer efcacy from FDA clearance.
A list of studies where lasers have been used is summarized in Table 12.4,
though as discussed above we feel that the Q-switched laser is probably an
ideal laser (Figs 12.4A and B) as it tends to optimize the target size of the
hyphae than the millisecond lasers. The sessions are spaced from 2 weeks to
4 weeks intervals.
Future
Melanin, present in T. rubrum and T. mentagrophytes, especially in
microconidia, may be selectively targeted by using wavelengths absorbed by
Fig. 12.4A: A case of distal lateral onychomycosis
Fig. 12.4B: Use of Q-sw Nd:YAG laser for treating onychomycosis (12 J/cm2 : 2 Hz)

Table 12.4 Laser used for onychomycosis
Author
Laser Used
Type
Fluence
(J/cm2)
Size (mm)
Pulse duration
(ms)
Carney et al
Laser Genesis
Nd:YAG 1,064
16
0.3
Gupta et al.
Joule Clear
Sense
Nd:YAG 1,064
13
Gupta et al.
Q-Clear
QswNd:YAG
1064 nm
14
Harris et al.
Pinpointe ,
Foot Laser
Nd:YAG 1,064
Landsman
et al.
Noveon
Diode
Lim EH
Fractional
CO2 Topical
Antifungal
cream
Moon SH
1,064-nm
long-pulsed
Nd:YAG
0.3
2.56
310
nanosecond
__ __ _
870/930
204424
15
6,5
0.3
Weiss et al.
GenesisPlus
Nd:YAG 1,064
16
300
Zhang et al.
Pinpointe ,
FootLaser
Nd:YAG 1,064
240324
30
melanin for which the Q-switched 1,064 nm Nd:YAG is ideal. The effectiveness
of the 1,064 nm laser was proposed to be a photothermolytic effect of laser
light absorption by melanin found in the cell wall of T. rubrum.
In addition to the selection of a melanin specic wavelength, the selection
of a pulse duration that matches the thermal relaxation of the target is
needed. The thermal relaxation time can be approximated to the square of
the diameter of the target. The small size of the melanin particle (0.1 mm)
requires the use of a pulse duration in the nanosecond range, such as that
provided by a Q-switched laser. In addition, the fungal structure can be
targeted by using pulse durations that match the thermal relaxation time
of dermatophytes. The thermal relaxation time of hyphae (210 mm) is
0.0040.1 milliseconds, macroconidia (450 mm) is 16 microseconds to 2.5
milliseconds, and microconidia (24 mm) is in the 0.0040.016 milliseconds
range. Thus, selective targeting of dermatophytes likely requires pulse
durations in the nanosecond to very low millisecond range.

Although, it may be possible to target fungus with selective
photothermolysis, many questions remain. The effects of the nail plate
on laser optics are unknown and need to be investigated. Further, is there
enough melanin and xanthomegnin present in the fungus to be effectively
targeted? Finally, are there other untapped target chromophores that would
be more effective? Additional studies are needed to answer these questions.
The most important issue is that all studies have variable cure rates,
end points, dosages and long-term data are not present. The mismatch
between in vitro and in vivo findings is a recurring theme. The study by
Hollmig ST is probably the first RCT where it has been proved that there is
no significant mycological culture or clinical nail plate clearance with 1064nm neodymium:yttrium-aluminum-garnet laser compared with control.
This has to be kept in mind, though we feel that using the fractional laser as
a topical delivery enhancing agent may be the most sensible method to be
pursued at present.
Bibliography
1. Carney C, Cantrell W, Warner J, Elewski B. Treatment of onychomycosis using
a submillisecond 1064-nm neodymium: yttrium-aluminum-garnet laser. J Am
Acad Dermatol. 2013;69(4):578-82.
2. Engelhardt-Zasada C, Prochacki H. Inuence of temperature on dermatophytes.
Mycopathol Mycol Appl. 1972;48(4):297-301.
3. Gupta A, Simpson F. Device-based therapies for onychomycosis treatment. Skin
Therapy Lett. 2012;17(9):4-9.
4. Gupta AK, Simpson FC. Medical devices for the treatment of onychomycosis.
Dermatol Ther. 2012;25(6):574-81.
5. Harris D, McDowell B, Strisower J. Laser treatment for toenail fungus. Proc SPIE.
2009;7161(71610M):1-7.
6. Hees H, Raulin C, Baumler W. Laser treatment of onychomycosis: An in vitro
pilot study. J Dtsch Dermatol Ges. 2012;10(12):913-8.
7. Hollmig ST, Rahman Z, Henderson MT, Rotatori RM, Gladstone H, Tang JY.
Lack of efficacy with 1064-nm neodymium:yttrium-aluminum-garnet laser
for the treatment of onychomycosis: A randomized, controlled trial. J Am
Acad Dermatol. 2014 Mar 15. pii: S0190-9622(14)00987-6. doi: 10.1016/j.
jaad.2013.12.024.
8. Landsman AS, Robbins AH, Angelini PF, Wu CC, Cook J, Oster M, Bornstein ES.
Treatment of mild, moderate, and severe onychomycosis using 870- and 930-nm
light exposure. J Am Podiatr Med Assoc 2010;100(3):166-77.
9. Lim EH, Kim HR, Park YO, Lee Y, Seo YJ, Kim CD, et al. Toenail onychomycosis
treated with a fractional carbon-dioxide laser and topical antifungal cream. J
Am Acad Dermatol. 2014 Mar 18. pii: S0190-9622(14)01024-X.doi: 10.1016/j.
jaad.2014.01.893.
10. Moon SH, Hur H, Oh YJ, Choi KH, Kim JE, Ko JY, Ro YS. Treatment of
onychomycosis with a 1,064-nm long-pulsed Nd:YAG laser. J Cosmet Laser Ther.
2014. [Epub ahead of print]
11. Paasch U, Mock A, Grunewald S, Bodendorf MO, Kendler M, Seitz AT, et al.
Antifungal efcacy of lasers against dermatophytes and yeasts in vitro. Int J
Hyperthermia. 2013;29(6):54450
12. Weiss D. 3 Month Clinical Results Using Sub-Millisecond 1064 nm Nd:YAG Laser
for the Treatment of Onychomycosis. Hammonton, NJ: Weiss Foot and Ankle
Center; 2011.

13. Zhang RN, Wang DK, Zhuo FL, Duan XH, Zhang XY, Zhao JY. Long-pulse
Nd: YAG 1064-nm laser treatment for onychomycosis. Chin Med J (Engl).
2012;125(18):3288-91.
Vascular Disorders
Though this topic has been discussed previously a few indications are covered
here.
Spider Hemangiomas
This is characterized by a central dilated vessel. They can be treated with most
vascular lasers. The laser used is a PDL or a high-powered 532-nm device. As
there is a large dilated feeder vessel, these lesions seem to respond best to a
40-ms pulse duration with energies of 1315 J/cm. Most IPLs, low-energy
532-nm lasers, and 980-nm diode devices can also be used.
We use the ultrapulse CO2 to target the central feeding vessels with
satisfactory results.
Angiokeratomas of Fordyce
These are typically asymptomatic vascular lesions characterized by blue-tored papules with a scaly surface, most often located on the scrotum.
These lesions are easily treated with both the pulsed dye laser and longpulsed Nd:YAG lasers, though we have found the pulsed CO2 an excellent
option. The pulse duration should be at least 0.20 seconds if a repeat mode
is used (12 W) to help coagulate the vessels. A defocused mode should be
used.
Glomus Tumor
Hereditary multiple glomus tumors constitute an autosomal dominant skin
disease that is known to demonstrate cutaneous mosaicism typied by type
1 and 2 segmental arrangements. These lesions characteristically can be
spontaneously painful. Pulsed dye laser treatment can be used to relieve pain
but may not be curative.
Telangiectasias
These represent dilated capillaries and post-capillary venules with thickened
walls. They are supercial (200250 mm deep) and have small cross-sections
(200500 mm in diameter).
The ideal laser is PDL though the associated purpura is a concern. A useful
setting is a longer pulse width in the 610 ms range utilizing pulse stacking
where two to four pulses are stacked immediately one on top of the other
until vessel clearing is noted. Another setting used is a longer pulse width in
the 2040 ms range; uences between 7 and 10 J/cm2 and spot sizes of 510
mm.
End Point: Immediate coagulation/graying that quickly cleares is the desired
endpoint.
The IPLs have also been shown to be effective against telangiectasias and
have a lower risk of inducing purpura and generally induce a mild erythema.
Effective uences range from 32 to 40 J/cm2 with pulse width of around 20 ms.
These are useful for larger matted telangiectasias and the diffuse erythema
associated with rosacea.
Venous Lakes
The venous lakes are very common about the lips and other mucous areas.
They are large vascular channels, which are often deeply situated and respond
to most high-powered, long-pulse devices with pulse durations of 2060 ms.
Laser therapy is often effective and needs to be tailored to the depth of the
target vessels. The lasers used include PDLs, 755-nm alexandrite lasers, longpulse Nd:YAG lasers, and the combined 595-nm/1,064-nm multiplex device.
PDL is often effective for supercial venous lakes, but the longer wavelengths
of diode (800900 nm), alexandrite (755 nm), or Nd:YAG (1,064 nm)
lasers are necessary for thicker or deeper lesions. Fluences of 80 J/cm2, pulse
durations of 60 ms or longer, and 1012 mm tips are often required, which
puts the epidermis at risk of being thermally damaged. Appropriate cooling
is therefore very important.
The aim with a PDL is to produce mild purpura and edema. With diode
and Nd:YAG lasers, the goal is reduction in lesion, thickness and clearance of
the ectatic vessel. For the larger and deeper lesions an Nd:YAG laser with a
spot size of 3 mm, pulse widths of 30100 ms and uences of up to 150 J/cm2
may be needed.
Wound Healing
The use of lasers for wound healing can be divided into two types:
1. Lasers to augment the healing of acute wounds (e.g. tissue welding,
tissue soldering).
2. Lasers for chronic wounds (e.g. low intensity laser devices).
Lasers for Acute Wounds

The main techniques of laser-assisted wound closure of acute wounds are:
simple tissue welding, tissue soldering, dye-enhanced tissue welding, and
addition of growth factors. The potential advantages of laser-assisted tissue
bonding over conventional methods include increased immediate wound
strength, uid-tight closure, decreased operative repair time, reduced
probability of infection and bleeding, and improved cosmetic results.

However, lasers have disadvantages such as their high cost, risk of dehiscence,
risk of thermal damage, and inconsistency of results.
The exact mechanism involved in laser-assisted wound closure is not
completely understood. The heat produced by laser energy in the tissue
causes collagen bers to lose their triple helix structure and become fused,
intertwined, swollen, and dissolved and thus lead to better wound healing.
Lasers for Chronic Wounds

Different lasers for treating chronic wounds include helium-neon, galliumarsenide (GaAs), gallium-aluminum-arsenide (GaAlAs), Nd:YAG, carbon
dioxide, ruby, krypton, and argon dye lasers.
The exact mechanism of action of low intensity laser therapy is not
known. Current hypotheses are: stimulation of Ca inux and mitosis rate,
increased expression of Heat-Shock-Proteins (e.g. HSP70), increased
expression of growth factors such as TGF-b, alteration of mitochondrial
activity and increased ATP synthesis, augmented formation of mRNA and
protein secretion, enhancement of broblast and keratinocyte proliferation
and migration, angiogenesis, improvement of phagocytosis, and increased
rate of transformation of broblasts into myobroblasts.
Conclusion
To better understand the role of low-intensity lasers in healing of chronic
wounds, well-controlled studies that correlate cellular effects and biologic
processes are needed. In the absence of such studies, the literature does not
appear to support widespread use of lasers in wound healing at this time.
Malignant and PreMalignant Disorders

Though an overview of some conditions is given below, the use of lasers
cannot replace the role of oncological referral, which should follow histological confirmation and precede any surgical intervention. Though Mohs
surgery is the ideal intervention in certain scenarios, lasers can be used. Updated guidelines can be accessed at http://www.nccn.org/. These guidelines
suggest that for precancerous disorders skin directed therapies may be tried,
including lasers, though they cannot match the results of Mohs surgery.
Zoons Balanitis
The rst goal of therapy is the promotion of good hygiene; circumcision is the
most consistently effective treatment. Topical steroids, antimicrobials, and
hormonotherapy have all showed inconsistent results.
The carbon dioxide laser is an effective treatment for Zoons balanitis,
especially if circumcision is not a feasible option, and, more recently, good
results with an erbium:YAG laser were reported (Albertini JG). The patient
was treated with an erbium:YAG by Albertini et al. and showed no clinical
or histological evidence of relapsing with complete re-epithelialization
occurring one week after treatment, similar to the patient treated with a
carbon dioxide laser by Baldwin and Geronimus. Nevertheless, in a series of
5 patients treated with a CO2 laser (Retamar RA) two patients relapsed after
1 or 3 years, with the third patient later developing lichen sclerosus.
Basal Cell Carcinoma/Squamous Cell Carcinoma

For low risk NMSC, skin directed therapies can be used, including imiquimod
5%, RT, PDT and cryotherapy (NCCN guidelines version 2. 2014).
Thus before laser therapy, one or more biopsies must always be taken to
conrm the diagnoses histologically. The following laser procedures have
been tried:
1. Ablative Lasers ( CO2 and Er:YAG)

The limits of laser procedures are inherent in the depth of penetration of the
lasers vis a vis the disorder that requires treatment.
According to Horlock et al., treatment with the CO2 laser is advantageous
especially for patients with histologically supercial BCC. In addition, the
extent of the ablation increases with the practitioners clinical experience.
In a study with 30 lesions (17 BCCs, 13 SCCs in situ), Humphreys et al. also
found that supercial lesions responded very well to treatment with the CO2
laser. In this study, an energy density of 500 mJ/cm2 in two to three passes
was used. With increasing thickness of the lesions, there was histologically
minimal thermal damage to the underlying tissue, so that after completion of
the laser treatment, residual tumor cells were still present.
2. Nd:YAG
Because of its limited penetration of 47 mm, the Nd:YAG laser is particularly
suitable for the treatment of smaller and atter tumors.
3. PDT and Similar Approaches

Photodynamic therapy (PDT) is becoming more widely used, especially in
the treatment of supercial basaliomas and squamous cell carcinomas of up
to 2 mm in depth. Although, this is an interesting and promising therapeutic
approach, the lack of long-term data means that it should not yet be regarded
as a routine procedure for nodular lesions.
Erythroplasia of Queyrat/ Bowens Disease

The standard treatment is micrographically monitored excision, preceded
in all cases without exception by a biopsy to conrm the diagnosis and
determine the depth of penetration. Alternatives available are curettage,

electro-desiccation, cryotherapy, topical application ofuorouracil,
imiquimod, PDT, and laser therapy.
The pulsed CO2 laser is now generally used for the treatment of Bowens
syndrome and erythroplasia of Queyrat. Numerous case reports of successful
treatment are available (Del Losada JP, Greenbaum SS). Martinez-Gonzalez
et al. describe a lasting success achieved in 85% of their cases after only
one treatment session with the CO2 laser. In 8% of cases, there was a later
recurrence. A total of 2% of patients did not respond to laser therapy. Vasse et
al. also report similar results in Bowens syndrome in one study (eight patients,
ten lesions). In a period of almost 3 years, there was a single recurrence of one
lesion.
A case report published by Wang et al. also describes a combined treatment
with the Er:YAG laser followed by topical application of 5-uorouracil in one
patient. It is not certain whether this procedure will eventually be accepted as
standard, because no long-term observations of patient populations are yet
available that would allow extrapolation of the results to other patients.
To keep the recurrence rate as low as possible, an adequate safety
margin must also be created in the healthy tissue when a laser surgical
technique is used. As seen in Figures 12.5 to 12.7, bleeding makes the use
of Er:YAG impractical. Very close follow-up monitoring is necessary, as with
all techniques, especially because complete removal of tumor complexes
cannot be absolutely guaranteed and there are still no adequate long-term
observations on recurrence rates available.
Fig. 12.5: A case of Erythroplasia of Queyrat
Fig. 12.6: A spot is treated with pulsed CO2 (Repeat Mode, 4 W, 0.20 sec). Note the
bleeding as the epidermis is ablated
Fig. 12.7: A few more passes are given till the elevated surface is ablated. A staged
approach should be used for laser therapy of malignant tumor
Pagets Disease
Extramammary Pagets disease is, by denition, an intraepithelial adeno
carcinoma that occurs with particularly high frequency in the genitoanal
region. There have been several reports of its treatment with the pulsed CO2
laser and the pulsed Nd:YAG laser.
Louis-Sylvestre et al. described recurrence rates of up to 67% after a year
after treatment with the pulsed CO2 laser; these rates can be reduced to 23%
minimum by combining the laser therapy with extensive surgical excision. In
a few cases it proved possible to achieve a disease-free state lasting up to 4.5
years with the combined treatment (Ewing TL).
For some time, PDT has been used with increasing frequency as an
alternative to the laser for treatment of Pagets disease (Shieh S). As of this
writing, however, there still have not been any studies about this disease
in large patient populations. The application of laser systems to date has
been based mostly on case reports. Because there also have been reports
of ineffectual treatments with the CO2 laser, careful consideration must be
given to whether laser treatment is indicated, and very close follow-up is an
essential part of the therapy (Puppala S).
Parapsoriasis/Mycosis Fungoides
Mycosis fungoides (MF) is a T-cell, non-Hodgkin lymphoma. Only in the early
stages where systemic involvement is not marked, skin directed therapies
are used. These include steroids, topical chemotherapy, RT, phototherapy,
imiquimod and retinoids(NCCN Guideliens Version1.2014).
Goldberg et al. had reported a successful treatment of palmoplantar
lesion with the pulsed CO2 laser in 1997. During a follow-up period of 5 years,
the patient remained free of recurrence.
Excimer laser has been used both in MF and parapsoriasis but in the
early stages of the disease. This type of laser is used because it is thought that,
compared with total-body irradiation with UV light, the selective application
of lasers makes it possible to protect healthy skin at the same time. Passeron
et al. showed that complete healing of circumscribed plaques can be attained
with a mean of 715 sessions and an average of 7 J energy applied per cm2.
These results remained stable for a total of 3 months. Mori et al. also used the
excimer laser in seven stage 1A lesions with complete lack of recurrence after
328 months. This was improved by Nictic et al. who achieved a recurrence
free interval of more than a year after treating ten lesions in the same stage;
a cumulative energy dose of 612 J/cm2 was applied. Upjohn et al., in a study
with 8 stage 1A or 1B patients, showed that after 20 treatment sessions with
the excimer laser, there was complete clinical and histological remission in
37% of cases, which persisted for at least 30 months. In a further 37%, there
was an initial clinical and histological remission. However, during the course
of follow-up there was a recurrence.
The PDT has also already been successfully applied in these conditions,
although as of now there are no long-term data about recurrence rates.
In summary, laser therapy can be a helpful complement to the treatment
of MF, especially in its early stages. Long-term results and studies of large
patient populations are not yet available.
Bibliography
1. Albertini JG, Holck DE, Farley MF. Zoons balanitis treated with Erbium:YAG
laser ablation. Lasers Surg Med. 2002;30:123-6.

2. Baldwin HE, Geronemus RG. The treatment of Zoons balanitis with the carbon
dioxide laser. J Dermatol Surg Oncol. 1989;15:491-4.
3. Del Losada JP, Ferr A, San Romn B, et al. Erythroplasia of Queyrat with urethral
involvement: treatment with carbon dioxide laser vaporization. Dermatol Surg.
2005;31:1454-7.
4. Ewing TL. Pagets disease of the vulva treated by combined surgery and laser.
Gynecol Oncol. 1991;43(2):137-40.
5. Greenbaum SS, Glogau R, Stegman SJ, et al. Carbon dioxide laser treatment of
erythroplasia of Queyrat. J Dermatol Surg Oncol. 1989;15(7):747-50.
6. Horlock N, Grobbelaar AO, Gault DT. Can the carbon dioxide laser completely
ablate basal cell carcinomas? A histological study. Br J Plast Surg. 2000;53(4):
286-93.
7. Humphreys TR, Malhotra R, Scharf MJ, et al. Treatment of supercial basal cell
carcinoma and squamous cell carcinoma in situ with a high-energy pulsed
carbon dioxide laser. Arch Dermatol. 1998;134(10):1247-52.
8. Louis-Sylvestre C, Haddad B, Paniel BJ. Pagets disease of the vulva: results
of different conservative treatments. Eur J Obstet Gynecol Reprod Biol.
2001;99(2):253-5.
9. Martinez-Gonzalez MC, Pozo JD, Paradela S, et al. Bowens disease treated by
carbon dioxide laser. A series of 44 patients. J Dermatolog Treat. 2008;11:1-4.
10. Mori M, Campolmi P, Mavilia L, et al. Monochromatic excimer light (308 nm) in
patch-stage IA mycosis fungoides. J Am Acad Dermatol. 2004;50(6):943-5.
11. Nistic S, Costanzo A, Saraceno R, et al. Efcacy of monochromatic excimer
laser radiation (308 nm) in the treatment of early stage mycosis fungoides. Br J
Dermatol. 2004;151(4):877-9.
12. Passeron T, Angeli K, Cardot-Leccia N, et al. Treatment of mycosis fungoides
by 308 nm excimer laser: a clinical and histological study in 10 patients. Ann
Dermatol Venereol. 2007;134:225-31.
13. Puppala S. Failure of carbon dioxide laser treatment in three patients with
penoscrotal extramammary Pagets disease. BJU Int. 2001;88(9):986-7.
14. Retamar RA, Kien MC, Chouela EN. Zoons balanitis: presentation of 15 patients,
ve treated with a carbon dioxide laser. Int J Dermatol. 2003;42:305-7.
15. Shieh S, Dee AS, Cheney RT, et al. Photodynamic therapy for the treatment of
extramammary Pagets disease. Br J Dermatol. 2003;146(6):1000-5.
16. Upjohn E, Foley P, Lane P, et al. Long-term clearance of patch-stage mycosis
fungoides with the 308-nm laser. Clin Exp Dermatol. 2007;32(2):168-71.
17. Vasse V, Clerici T, Fusade T. Bowen disease treated with scanned pulsed
high energy CO2 laser. Follow-up of 6 cases. Ann Dermatol Venereol.
2001;128(11):1220-4.
18. Wang KH, Fang JY, Hu CH, et al. Erbium:YAG laser pretreatment accelerates the
response of Bowens disease treated by topical 5-uorouracil. Dermatol Surg.
2004;30(3):441-5.
Conclusion
The data and experience given here is possibly a birds-eye view of the
plethora of indications and lasers that can be used. But it is the experience
of this author that most of the indications that have consistent response are
while using the conventional ablative lasers. The use of excimer lasers in
pigmentary disorder may be justifiable, but in pigmented skin, the result may
not be different from conventional treatments (e.g. PUVA in vitiligo). As far as
malignant cases are concerned, lasers do not find any mention in the NCCN
guidelines (http://www.nccn.org/default.aspx) and should be used only in
the premalignant conditions.
The use of lasers in hair and nail disorders has received FDA approvals,
but there is still a need for multiple, RCT, on these conditions with long-term
follow-up with preferably comparison with conventional modes of therapy.
Chapter
13
How to Start a Laser Practice

(Private Setup)
Anil Ganjoo
Use of lasers, in dermatology, has been rapidly increasing. Over the last 4 to 5
decades, that lasers have been around, there have been rapid advances in the
technology and therapeutic efficacy of lasers. Extensive research has given a
better understanding of the laser tissue interaction and this has allowed us
to expand the therapeutic options with lasers and has improved the clinical
outcome. Lasers have now become the treatment of choice for a number of
conditions that were thought to be virtually untreatable about 5 decades ago.
Since their inception about 50 years ago, lasers have come a long way. From
the initial use of ruby laser for almost every condition to highly precise laser
for each condition we have progressed a lot.
With the advances in technology have come the advances in the
availability of large number of different types of systems and large numbers
of dealers dealing in similar systems, which has made the laser scene very
complex and confusing. Selecting the right system and the right dealer is of
utmost importance for a good laser practice.
We have been using lasers in India for the last about 15 years and this
decade and a half experience has taught a lot of lessons. While working on
our patients we have found that our kind of skins behaves differently than the
western skins. Therefore we have developed our own parameters that suit our
patients skins. We now know that if used judiciously lasers are wonderful but
they have their shortcomings.
When planning a laser set up, one should be well aware of the laser
physics, which will help in selecting the system with the right parameters. To
begin, the physician should know:
His budget
His patient profile
His patient volume
His patients paying capacity.
The budget situation decides what kind of investment can be put in and
therefore what kind of machines can be bought. Depending upon the type
of patients one sees in practice, he can decide as to which system should be
How to Start a Laser Practice (Private Setup) 417
his first priority. One should be able to foresee what procedure would be in
greatest demand in ones practise. For example, if the physician has a lot of
young and old hirsute women walking in then the first system that is bought
should obviously be a hair reduction system, while if you get a lot of scars
then a fractional resurfacing system should be your choice. Only those with a
good volume of patients should plan to set up a laser practice as high turnover
of patients is necessary for recovering the high cost of the machines. Last of
all, the area that you are practicing in is very important as that determines
whether the patients will be able to pay the high costs involved.
One of the most common questions asked by the starters is whether
to start with a platform with multiple functions or to go for a standalone
machine. In practice, buying stand alone systems is always more beneficial
as they are more effective than the combinations and also if a platform breaks
down all your lasers will break down while if a standalone machine breaks
down only that particular wavelength is gone.
While buying a new system one should look for:
The best specifications.
Whether that particular system is being used by other colleagues.
The reliability of the dealer.
The after sales record of the dealer.
System specifications
Specifications of the machine are the most important deciding factor to pick
up a system.
For hair reduction following systems are available in India:
1. LP Nd:YAG
1064 nm
2. Diode
810 nm
3. Alexandrite
755 nm
4. IPL
4001200 nm
5. In motion technologies

a. Diode

b. IPL.
Long pulse Nd:YAG is the safest due to the longest wavelength. Diode
is slightly more efficacious but can produce side effects like burns and
pigmentary disturbances, particularly in our kind of dark skins. IPL systems
is the classic jack of all trades masters of none. They can do multiple jobs but
their efficacy is not comparable to the standalone wavelengths. In general,
the machine you buy should have a large spot size available as larger the spot
size, leser is the scattering and deeper is the penetration. The system should
have variable pulse width10 to 100 milliseconds, which ensures targeting
hairs of various thicknesses. Above all the machine should have good power
and should be sturdy.
The lasers used for pigmented lesions are the Q-switched lasers. These
include:
1. Qs frequency doubled Nd:YAG laser
532 nm
2. Qs ruby laser
694 nm
3. Qs alexandrite laser
755 nm
4. Qs Nd:YAG laser
1,064 nm
5. IPL
5901,200 nm
In India, the most commonly used is the Qs Nd:YAG system
1. 1,064 nm
2. 532 nm.
All Q-switched machines have pulse widths of < 10 nano secs. High end
machines with variable spot sizes of 2/4/6/8 mm are desirable. The machine
should have a good power, with maximum fluence of at least 12 J/cm2, using
the smallest spot size. Considering the cost constraints, people often prefer
to buy the cheaper machines. However, cheaper machines with a single
spot size of 2 mm and maximum energy output of 500600 mJ/cm2 are not
recommended. IPL is not a very good option for pigmented lesions.
Fractional lasers are the new wonder machines that are now used for
an increasing number of indications, major one being resurfacing for scars
and ageing skin. These are available as ablative and non-ablative versions
and both are quite effective. The ablative CO2 fractional laser gives the fastest
and the best results but has a long downtime. Superficial scars can be taken
care of with Erbium:YAG 2,940 nm fractional. It is thus the authors opinion
that the results of nonablative fractional lasers, like Er:Glass 1540 nm, are
not comparable to that of ablative lasers. While buying a CO2 fractional
machine one should make sure that the power of the machine should be at
least 30watts to 40 watts, the pulse width should be 500 ms to 600 ms and the
machine should have variable density of spots thus.
Less density with high power can be used for deep scars, while more density
with low power can be used for rejuvenation and textural improvement.
Dealer Reliability
Before buying a system try to integrate the evidence-based literature and
experience of your peers who have been using that particular system or who
know about it. Literature based evidence is hard to find since most of the
machines have different specifications. But if available, can be a big help and
confidence building measure. Peer advice is easy to get. Try to get in touch
with colleagues who have been using the same system for some time. They
are the best people to guide you about the working of the machine and also
about the reliability of the dealer. It is better to believe what the peers say than
to listen to what the manufacturers or the dealers say.
Reliability of the dealer is a huge concern. Checking the credentials of
the supplier is as important as the specifications of the machine itself. One
How to Start a Laser Practice (Private Setup) 419
should do a thorough market survey with inputs from colleagues and market
experts before putting faith in a particular dealer. The dealer should be of good
repute, should have an expert team of engineers who can provide a good post
sale service. The office of the dealer should preferably be in your city so that
he can be easily approached. Execute a proper contract of purchase which
should include all aspects of warranty. Make sure that the warranty clearly
mentions the time of warranty and the parts covered under it. Sometimes the
parts that really need to be covered are not covered under warranty. These
include parts that are more likely to wear out soon like the flash lamp, the
optic cable, the lenses and the mirrors. Keep your eyes open to the possibility
of getting a refurbished machine instead of a new one. So ask for import
details of the machine including the papers of point and date of entry into the
country and check whether the serial number mentioned on the papers is the
same as that of your machine. Be in touch with the parent company through
emails to make sure that a new machine has been imported directly from the
parent company.
Once the machine has been procured, have a written agreement with the
company mentioning:
Likely breakdowns
Warrantyparts covered
Cost of components that usually breakdown
AMC after the warranty is over
Most AMCs do not cover the commonly required components like
fiber, flash lamps, power supply, etc. Service contract may also serve
the purpose. At times you need to send your machine to the parent
company in Europe/US to get it repaired. So do a proper homework and
assess the post-sales performance of the company whose machine you
intend to buy
Insuring your machine is a good idea
Installing a UPS is very useful as it ensures

Uninterrupted power supply

Prevents damage due to voltage fluctuations.
Also remember that maintenance is an expensive affair as spares are quite
costly. Considering the high initial cost and the expensive maintenance, it
is always better for a few colleagues to get together to set up laser practice.
This shares the cost of buying and maintenance and also increases the patient
pool and more the number of patients treated better the cost effectiveness.
Avoiding Common Mistakes

The single most common mistake is to obtain every single device in the
market, buy every single handpiece on the platform and to get the latest
and the greatest. While it is always tempting to do so it can be a big mistake
also. Patients are looking for results and good outcomes. Bad results can
spoil the reputation of the physician very easily. So try to get time-tested and
result-oriented machines rather than the latest and the most expensive. The
second common mistake is not accounting for all costs (direct and indirect).
True costing should include all the overheads like electricity, time, staff,
breakdowns, etc. A business plan with real return on investment (ROI) should
be chalked out for each machine. Do not rely on the manufacturers ROI plan.
Instead ROI should be based on maturity of practice, size and type of practice
and competition in the market.
Conclusion
The field of lasers and light devices is undergoing a huge revolution. There
are a large number of machines available in the market that makes decision
making a very difficult exercise. It is imperative for the physician to approach
the issue in a stepwise manner. This includes:
1. Evidence based review and discussion with peers on the specifications
of a particular system.
2. Assessment of the reliability of the dealer/manufacturer.
3. Working out a proper contract on sale and post sale service including
the warranty.
4. Working out the real return on investment on the product considering
ones practice in volume and demography as also the market competition.
Remember if procured carefully and used judiciously, lasers can be a big
boon to the dermatology practice.
Further Reading
Books
1. Carbon dioxide and erbium YAG lasers In: Goldman MP (Ed). Cutaneous
and cosmetic laser surgery, 1st ed. USA: 2006.
2. Skin resurfacing with ablative lasers In. Goldman MP (ed). Cutaneous
and cosmetic laser surgery, 1st Ed. USA: 2006.
Journals
1. Alster, Cut resurfacing with CO2 and erbium: yag laser. Plast Reconstr
Surg. 1999;103:619-322
2. Alster TS: Clinical and histologic evaluation of 6 erbium: yag lasers for
cutaneous resurfacing. Lasers surg med. 1999;24:87-92.
3. Jaisn ME: Achieving Er:YAG superior resurfacing results with the Er:
yag lasers. Arch facial plastic surgery. 2002;4:262-6.
4. Tissue effects of the Er: yag laser with varying passes, energy, and pulse
overlap. Lasers Surg Med, 1998;22(suppl10);70.
Chapter
14
How to Set up a Laser Clinic

in a Public Funded Institution
Kabir Sardana, Atul M Kochhar
Introduction
Though a previous chapter covers the topic in a private set up, as some readers
may be in Government aided colleges, a perspective of how to set up a laser
center is being given below.
Why buy Lasers?

A trivial question with far reaching implications. Laser has become a part of
dermatological practice, but it is not justified to expend money on all sorts
of lasers. It is the authors opinion, that three basic principles must be met
before ordering a laser, presuming of course that trained personnel are there
to run it.
1. Lasers with a purely cosmetic need (like hair removal) should not be
bought in a medical college government set up. This is as firstly they are
time-consuming procedures and secondly are so well researched that
there is little need for further studies on it. Moreover, the number of hair
removal procedures in private set up are so many that nothing new can
emanate out of a medical college experience. Another issue is that the
laser clinic tends to be overrun by such patients leaving little time or
energy for anything else! Finding approvals to spend public money on
them of course is another matter.
2. Lasers where a research into new therapies or aspects of laser physics are
needed should be bought. This includes fractional lasers and possibly
novel pigment specific lasers.
3. Lasers should be bought for conditions that have organic and cutaneous needs, like scars, benign tumors, tattoos, nevus of Ota,vascular conditions where the costing in private centers is prohibitively high. Conversely where the cost of machine is not so high, like a good pulsed CO2
lasers, is a sensible buy as this can tackle most tumors, though having
used the Er:YAG for a long time an ideal situation would be to have both
the ablative lasers.
Which lasers to buy?

We are detailing a list of lasers that could be bought. This is based on almost
8 years of running, buying and maintaining lasers at our institution. Every
center tends to justify its purchases and it is possible that there may be
differences of opinion, but as tendering (see below) goes through multiple
committees, justifying laser buys is difficult, if the needs of the government
and the patients are not matched. It is difficult to justify say a laser lipolysis or
a RF machine in most medical colleges!
Ablative Lasers
Though most centers buy the CO2, we would recommend that if possible this
should be specified as a ultrapulse CO2 and possibly a Er:YAG, the latter of
which is one of the safest lasers with a predictable depth dose equation. The
newer modulated Er:YAG lasers are even safer and better.
As a thumb rule for epidermal and most dermal disorders, the Er:YAG is
ideal and for vascular and lymphatic tumors, the CO2 laser is ideal.
Pigment Specific
The large number of pigmented disorders in Indian skin calls for special
techniques and apparatus to treat them. For most epidermal disorders, any
Qsw laser will suffice, though in our skin type the Nd:YAG is preferred. This
comes in two forms, 1,064 and 532 nm which covers most disorders.
For dermal disorders like nevus of Ota and tattoos, ideally a laser with
variable spot size is useful. As not all tattoos will respond to the Nd:YAG,
so if finances allow a ruby laser would be a useful addition! Though we can
forewarn the reader that justifying it will be difficult in Indian skin types!
Vascular Laser
Though the PDL is the ideal laser, it has three issues. Firstly the wavelength
and pulse duration has to be optimized, secondly the results in PWS are good
only if treated early and lastly the specifications have been set largely for
western skin types. The added problem of the consumable (dye) makes it a
costly endeavor.
But as the cost of therapy, say for PWS is so high in practice, we feel that a
government set up should have one, if finances allow!
Fractional Laser
The laser system is used largely for acne scars and rejuvenation, though a
multitude of other uses exist. The advantage of buying this is that usually
two or more probes can be bought with a system that can cover a range of
indications. If a platform is bought, an ablative and a pigment selective probe
can also be bought subsequently, which would be easy to justify.
How to Set up a Laser Clinic in a Public Funded Institution 423
But there is little in vivo difference between buying a Fr Er:YAG. Fr Er:Glass

and Fr :CO2 though there may be in vitro differences, thus it is better to buy
anyone fractional laser and optimize the settings!
It is a must to insist on US FDA or CE approved laser (see below) with
histological dose depth studies. The latter is useful to use the proper dosage to
target the pathology.
Hair Removal Lasers

We do not find sufficient reason to justify its use in government medical
colleges as it has little use apart from hair removal. Though the IPL was touted
as a multiple use laser, in our experience, it is a jack of all trades, master of
one , the one being hair removal!
Moreover, purely on a research point of view, the number of hair removal
procedures done in private centers are so many that little can be added to the
existing data. Except for certain procedures like hair removal for scalp grafts,
there is little use of this system in a public funded set up.
Excimer Laser
The cost of the system, the abundant sunlight in India, cheaper phototherapy
units and focused area of impact make it of little use in disorders like psoriasis
and vitiligo. Even if a local area is resolved, these being generalized systemic
disorders, we cant justify this equipment in a government set up. We have
detailed on this aspect in the Chapter 12.
Subsurface Lasers, RF, Laser Lipolysis, LLT

These systems, no doubt useful, achieve subsurface tightening, marginal
growth of hair and minor reductions in fat. None of these can be justified,
specially as they are prohibitively costly! Interestingly though they are all
FDA approved, thus not all FDA approved systems should be necessarily be
bought in a public funded institution.
To Delegate or Not to Delegate?

Energy based devices have rapidly become delegated procedures. It is
advisable not to do this as they are costly equipments and most passing
residents tend to hone their skills, sometimes based on little formal
knowledge. Each laser has nuances and it is our experience that the life of
the laser is directly proportional to the use and the latter is related a lot to the
misuse of lasers. Also a dedicated day should be allotted to laser clinic to
avoid misuse.
At the end of the day, it is the department head on whom the problems
will lie on if things go wrong. At that time, placing a blame on the concerned
person will be an issue if all and sundry have had a free hand with lasers. We
recommend a dedicated day, place and trained personnel to operate lasers.
Laser Procurement In Government Institutions

How to buy the right Laser with public funds?
Laser treatment is the new buzz word for dermatology, is growing day by day
while the side-effect profile is going down.
Though a detailed discussion of procurement is beyond the scope of this
book as laser purchases are expensive. An overview is given below:
1. Need assessment:

a. Scope of services of the hospital
A primary or even a secondary level hospital does not need lasers
and such a request is rarely entertained

b. Free or paid services
Though not always the norm some institution charge a fee that helps
to justify a purchase of what is largely believe to be a cosmetic need

c. Cosmetic or therapeutic machine
This is probably the most important indicator. Thus it is impossible
to justify a hair removal laser, though a IPL which has, at least in
theory, multiple uses can be requisitioned. Taking it further, a
hospital with a Nb:UVB unit should not ideally ask for a excimer
laser as again it is difficult to justify it for largely the same indication
as phototherapy

d. Manpower/space requirements
The former is probably more important and thus it is better for a
medical college where there are residents to assist the primary care
providers, to have a laser unit, as then usually routine cases can be
handled even if there is a paucity of staff

e. Budget considerations.
2. Framing the specifications: This is probably one of the few things
that can decide the future of the machine. We have detailed the steps
for FDA approval and verification which can help the buyer to decide
worthiness of the laser company:

a. Discussion in the departmental scientific committee

b. Formulation of generic specifications

c. Discussion on minimum standards acceptable

d. Consensus

e. Optional accessories required.
3. Forwarding the proposal:

a. Sample standard demand performa

b. Signature of at least 3 consultants

c. Adequate justification for the procurement.
4. Discussion with the hospital purchase committee/third party
coordinator: To add a level of fairness (occasionally delays) an external
expert is asked to vet the proposal. This helps to take care of any legal or
financial issues that may arise:
a. Scrutiny of proposal
b. Comments on justification
c. Is the purchase commensurate with the treatment services scope of
the hospital?
5. Procurement process: This step is crucial to purchase and requires a
deep understanding of procurement policies of the government. The
listed points might seem bureaucratic but happen to serve the dual
process of verification and validation. It is the authors opinion that
these steps have to be accepted and negotiated to properly purchase a
machine

a. Understanding the GFRFundamentals of e-procurement

b. The tender document

c. Vetting the proposalHOD, accounts, competent authority

d. Terms and conditions including after sales service, AMC

e. NIT

f. Tender schedule

g. Formation of committees

h. Tender openingPrequalification bid

i. Technical bid

j. Financial/price bid

k. Negotiations (if any)

l. Agreement to purchase

m. Letter of credit

n. Dispatch of machine

o. Freight and delivery

p. Installation

q. Trials

r. Commissioning of machineSOP

s. Installation certificate

t. Release of balance payment

u. AMC.
Regulatory Approvals
This means appropriate FDA 510(k) approvals in the USA, PMA, Health
Canada in Canada, TGA in Australia, Ministry of Health, Labor and Welfare
(Kohseishou) in Japan, appropriate CE marking for medical devices in
Europe, and so on.
Beware of claims like Approved by the FDA, the latter of which usually
simply means a letter from FDA recognizing that the system is a nonsignicant
risk device (NSR) or minimal risk device (MSR). This is not an approval to
market, but is simply a guide based on which the institutional review board
(IRB) of a research center can classify the system when it does take part in a
properly structured study.
FDA 510(k) Clearances

Section 510(k) of the Food, Drug and Cosmetic Act requires device
manufacturers who must register, to notify FDA of their intent to market
a medical device at least 90 days in advance. This is known as premarket
notificationalso called PMN or 510(k). This allows FDA to determine
whether the device is equivalent to a device already placed into one of the
three classification categories.
Thus, new devices (not in commercial distribution prior to May 28, 1976)
that have not been classified can be properly identified. Specifically, medical
device manufacturers are required to submit a premarket notification if
they intend to introduce a device into commercial distribution for the first
time or reintroduce a device that will be significantly changed or modified
to the extent that its safety or effectiveness could be affected. Such change
or modification could relate to the design, material, chemical composition,
energy source, manufacturing process, or intended use.
A simple way of confirming this is by, one, asking the company for a letter
from FDA (see Figure 14.1 sample letter). A second method, which is a back
up method is depicted in Figure 14.2 and 14.3.
For any individual spending money on a laser, it makes a lot of sense
checking the clearance on the FDA site. Of course once you settle for a nonUS FDA machine then this approval does not matter. But it should be made
clear that inappropriate use of a unapproved laser is a common litigation
claim and at least a CE approval must be obtained (Fig. 14.4)!
Looking Beyond the Price

Ask the following questions before just haggling the price, which though is
important may not matter if the device does not deliver results.
1. Internal trials if any?
2. Published data if any? (see below)
3. Histological depth penetration studies for fractional lasers.
4. Dose intensity parameters for your skin type.
5. Follow-up studies if any?
6. Postmarketing and service team site and offices. Verify the numbers and
address.
7. Import license and dealership registration
8. Proof of a firsthand device. Some lasers have been reused and sold!
9. Any legal issues, merger, acquisitions of the company
10. Any complications reported.
What Has Been Published on the System/Technology?

There are various types of publication and though most believe or are made
to believe that not all laser can have publications, but it is our opinion that
Contd...
Fig. 14.1: Sample letter of US FDA approval for a medical device
Fig. 14.2: Site of US FDA 510(K) approval. Enter the approval

number and click on search
Fig. 14.3: Site of US FDA 510(K) approval. The exact approval

date and device is verified
investing in a machine with published studies has a lot more value, even
though we admit that occasionally authors may have conflict of interests.
What you are looking for here are papers by reputable authors published
in the indexed and peer-reviewed literature, or at least in well-established
and peer-reviewed journals (15 or more volumes). A list of such journals is
given in the Appendix. A citation index is added to help further buttress the
validity of data (See Appendix in the end of the book).
An alternative source is appropriate chapters in books from reputable
publishers. What you should not fall for are so-called white papers which
any manufacturer can produce to look like a genuine publication, or articles
Fig. 14.4: CE Approval letter for medical device
from the commercially-oriented medical press unless they are also in turn
backed up by real papers. In India, like in many parts of the world, such
scientifically sounding journals abound and are not listed for obvious
reasons in the Bibliography!
The most deceptive ploy is where the sales person gives a study on
the technology, but of a different company! Make very sure that the articles
offered by the manufacturer/salesperson are on their specic system and
wavelength(s). There is a lot of difference between approved systems and a
unapproved system and often the intensity, dose or even wavelength is not
the same as in the published articles.
Conclusion
Though the regulatory approvals and procedural systems involved are
daunting, the take home message is simple, ask for validation, proof of
effectiveness, regulatory approvals and published studies. Buying a machine
on hearsay and exhortations of speakers in conferences is probably the most
foolish method of buying lasers. More importantly as all such procedures
are open to medicolegal scrutiny it is better to have the right device as the
approvals are a useful method of buttressing claims of good practices in
the court. The cost of litigations and damages can often negate the temporary
gains that may ensue by buying an unapproved and cheaper device.
Chapter
15
Therapeutic Pearls in Lasers

Ganesh S Pai, Pavithra S Bhat, Dharmendra Karn, Narendra Kamath, Anusha H Pai
In this age of information, ignorance is a choice. To be aware of more

effective treatment and to make the best use of lasers, useful inputs from
experienced hands are necessary. Photomodulation, photothermal and
photobiochemical processes of non-ablative nature are safe to use by
beginners. Photothermolysis is ablative in nature. The energy levels are much
higher and there is selective photothermal destruction as in Qsw 532/1064
lasers and nonselective photothermal as in carbon dioxide and erbium
lasers. Fractional photothermal as a concept involving microscopic patterns
of thermal injury has led to great safety in ablative resurfacing of scars.
The thermal relaxation time of pulse carbon dioxide laser heated tissue
is about 0.8 ms. In effect for the CO2 laser wavelength, we must deliver the
necessary 5 J/cm2 in at most a 0.8 ms pulse, preferably less, if we expect to
minimize injury to the underlying tissue.
When the UltraPulse mode is used (Fig. 15.1), the zone of ablation is
deeper but the zone of thermal damage is narrow.
In comparison when the continuous wave (Cw) is used, zone of ablation
is small, but there is a wide zone of the thermal damage and increased char.
In effect, the Cw mode is only useful for lesions on the surface of the skin (Fig.
15.2).
It is clear from the Table 15.1 that the upper eyelid has thinnest epidermal
structure of 25 m. Thus great care has to be taken to reduce power to the
tissue, in comparison to cheeks (Tables 15.2 and Fig. 15.2).
The erbium laser has a much lower depth of ablation and thermal damage
than CO2 lasers. They are thus much safe to use for superficial lesions. Because
of its high water affinity, the erbium loses its efficacy to penetrate the dermis
as it meets the fluid interface at the dermoepidermal junction. Thus, it is
relatively ineffective for acne scars which are placed in the mid-dermis.
Fractional carbon dioxide laser operates near tissue ablation levels but
only up to the fourth pass. After that, the energy is diverted to bulk healing
rather than ablating tissue. This damages adjacent normal tissue and there is
a risk of necrosis, delayed healing and scarring.
Therapeutic Pearls in Lasers 433
Fig. 15.1: Comparison of fractional CO2 laser pulse widths ~1.0 ms
Fig. 15.2: Importance of pulse duration on tissue effect using the CO2 laser
ACNE SCARS
While treating acne scars, it is important to use deep fractional ablation in the
base of the scars and lesser energy to reduce the sharp edges at the shoulder
of the scar. The safest lasers are those which emit high power, high energy and
short pulses.
Fractional CO2 lasers are an excellent tool for acne scars in young patients
(Figs 15.3A and B) but in middle-aged patients (Figs 15.4A and B) with sagging

Table 15.1 Variation in skin depth and density of adnexal structures
Skin site
Epidermis
(m)
Papillary
dermis (m)
Reticular
dermis (m)
Hair
follicles
Sebaceous
glands
Sweat
glands
Forehead
120
95
1700
Average
Average
Poor
Upper eyelid
25
40
437
Poor
Poor
Poor
Lower eyelid
40
45
412
Poor
Poor
Poor
Mid cheek
125
135
2100
Average
High
Poor
Lateral
cheek
120
97
2000
Average
Average
Poor
Upper lip
131
110
2000
Average
High
Poor
Upper neck
115
115
1460
Poor
Poor
Poor
Mid neck
75
71
1407
Poor
Poor
Poor
Low neck/
decolletage
70
60
1200
Poor
Poor
Poor
Adapted from G Sasaki Journal of cosmetic and Laser Therapy. 2009;11:190-201
Figs 15.3A and B: Fractional CO2 laser treatment for acne scars in a young patient

Table 15.2 Comparison between the CO2 laser and Erb:YAG laser
Parameter
CO2 laser
Erbium:YAG laser
Wavelength
10,600 nm
2,940 nm
Depth of ablation
20 mm
1 mm
Thermal damage
6080 mm
515 mm
Ablation threshold
5 J/cm2
1.5 J/cm2
Figs 15.4A and B: Fractional CO2 laser treatment for acne scars in middle-aged patient
of mid face, the procedure is not useful and may in fact trigger melasma in
susceptible patients. Routinely in all patients with PIH post-fractionated CO2
laser, a fractionated Qsw 1,064 nm can be used to hasten dispersal of pigment
three weeks after the procedure.
Chemical reconstruction of skin scars (CROSS) is a unique technique
using application of high concentrations of trichloroacetic acid (TCA) on
atrophic scars, focally to induce inflammation followed by collagenization.

This technique alone has shown reduction in the appearance of scars and
cosmetic improvement. Our experience has shown that combination of
CROSS technique followed by ablative fractional laser shows better and early
outcome in the management of scars. The combination of TCA and fractional
laser both have synergistic effect to induce neocollagenesis.
Keloids
Treatment of keloids on bearded areas such as jawline with CO2 lasers is
meant to debulk tissue. Hair removal with a diode laser removes a source of
constant stimulation of keloids as well as the repeated nicks and cuts caused
by a razor blade while shaving.
Epidermal Nevi
Epidermal nevi can be ablated by CO2 laser in a fractionated mode; but may
need three sessions at monthly intervals. After an ablative laser, the wound
needs regular dressings with ointment-based antibiotics as desiccation of a
wound delays healing, leaves crusts and causes scarring. (Figs 15.5 to 15.8).
Patients with light eyes need more care as pigmentation is difficult to
remove post-procedure.
PIGMENTED LESIONS
Melanocytic Nevus
While using a Qsw 1,064 nm laser for pigmented nevus, one must ensure that
it is not a dysplastic nevus (DN). DN is a marker for increased melanosome
risk. Its clinical characteristics are that it is greater than 5 mm in size, has
flatness and has variable pigmentation and irregular outline. A biopsy report
before attempting the laser is advisable. Plastic surgical removal is preferable
to laser removal in case of dysplastic nevus. More details have been detailed
in a previous chapter: (Laser Treatment of Common Pigmented Conditions).
Freckles
Freckles on patients with fair skin and brown hair respond well to 532 nm
wavelength, but relapse and constant extra sun protection is essential.
Tattoo
While considering tattoo removal, it is important to understand that there is
no single laser that can treat all tattoos.
Fig. 15.5: Prelaser photograph of a case for periorbital rejuvenation
Fig. 15.6: Postoperative crusting and erythema
Fig. 15.7: Scarring postoperative view showing sign of scarring
Fig. 15.8: Eventual healing with good textural improvement
Amateur tattoos contain elemental carbon and professional tattoos

contain organic dyes and metallic elements. Sometimes, patients with recent
tattoos complain of itching and redness. Red tattoo pigments which contain
mercuric sulfate and cadmium sulfide which is used in yellow tattoos and is
associated with allergic reaction.
Red and green colored tattoos are relatively resistant to Q-switched
Nd:YAG-lasers than blue or black colored ones. For resistant tattoos a
combination of ablative fractional laser followed by Q-switched laser
increases the tattoo clearance, reduces blistering, shorten recovery and
diminish treatment induced hypopigmentation. Ablative fractional
resurfacing (AFR) may enhance tattoo clearance through several possible
mechanisms. These include transepidermal elimination of the tattoo and the
associated inflammatory and phagocytic reacation, which helps to enhance
the removal of the tattoo pigment. A recent technique uses a combination
of UltraPulse CO2 and Qsw Nd:YAG which helps to rapidly remove tattoos
(Sardana K).
Whereas, 1,064 nm Nd:YAG is the work horse for black ink and 532 nm for
red pigment it is the Q-switched alexandrite 755 which is the gold standard to
remove green tattoos.
Paradoxical darkening can take place while using a 1064 nm Qsw laser
as the ferric oxide is reduced to ferrous oxide which is black in color. Such
tattoos can then only be removed by an ablative laser such as erbium or
fractional CO2 laser.
A detailed description of procedures and scenarios is given in the Chapter
Laser Treatment of Tattoos.
HAIR REMOVAL LASER

Patient selection should be done with caution for the best results. Patients
with thick, dark, terminal hair are the ideal subjects. Patients with darker skin,
lighter hair, co-existent endocrine disorders, irregular visit schedules, and
damaged skin tend to need more sittings, and response will be unsatisfactory.
Insist upon a patient having a stubble before the procedure as it helps in area
demarcation, and also ensures intact rootsthe melaninrich target of the
laser. Gray hair does not get cleared by laser, while light/blond hair demand
more sittings or a higher dosing.
Areas to be worked upon should be discussed before the procedure. If the
procedure demands a shaping of the hairline edge like beard-line, request
the patient to mark the area to be cleared before the procedure.
Postpone the procedure in patients who have a recent history of retinoids
usage, abrasive procedures, sun damage, chemical peels on the area, and
any damage to the local skin. Immunocompromized patient should not be
treated by lasers.
Procedure
The area to be worked upon needs to be marked upon with a skin marker
pencilwash proof, colored eyeliner pencils. White markers are the ideal
choice. Never use dark colors like black, purple, deep blue, as these may
absorb the laser and cause a local burn. If the adjacent area is a hairy region
(forehead), the hair edge is best covered with a tape to prevent singeing of the
intact hair.
The cool tip of the laser may be supplemented with use of refrigerated
ultrasound gel caution needs to be observed in dark patients, and in naturally
pigmented areas, dense hairy areas, adjacent to tattoos/pigmented nevi and
near pigmented scars.
The handpiece of the machine is heavy and this needs a steady wrist to
achieve the in-motion procedure. In case of in-motion technique, it is
always advisable to divide large fields like abdomen, back and limbs into
grids to ensure optimal dosage in all areas.
Postprocedure
Minimal transient erythema may be observed in some patients. Open areas
may be covered up with sunscreens.
The sapphire tip of the handpiece needs to be cleansed off the jelly
immediately to prevent drying of the same.
The hair root and buried part of the bulb hair will be extruded over the
next week following the treatment.
About 510% patients may observe a self-limiting folliculitis in the areas
while the upper lip area may show persistence of hairs near the angle of the
mouth.
COMPLICATIONS IN LASER SURGERY

Postinflammatory Hyperpigmentation
PIH may become apparent between 2 weeks and 2 months after postoperative erythema has resolved. As soon as re-epithelialization is complete
and erythema is resolved, topical bleaching regimen may be prescribed.
Post-inflammatory hyperpigmentation is usually reversible over time. It can
take between 36 months and can be easily concealed with makeup.
Hypopigmentation
May be clinically apparent 1 to 6 months after treatment. It is more commonly
observed on darker skin types and often related to the depth of resurfacing
or to the usage of inappropriate laser parameters. Sun exposure must
imperatively be avoided; it may actually worsen the change of pigmentation
and its duration. It may last for 612 months and rarely could be permanent.
Proper eye protection is essential. An eye shield is a must if treatment is

within orbital rim.
Technical Aspects
Smoke evacuator designed for surgical lasers: Connect tubing and cables
of the smoke evacuator as per manufacturers guidelines and as indicated
in the operators manual. Make sure filters have still operating hours left. In
addition, the physician should wear a micron filtered mask during procedures.
BOOKS
1. CO2 laser resurfacing: Confluent and fractionated. Cosmetic
Dermatology: Products and Procedures; 2010.
2. Hruza, GJ; Avram Dover JS. Lasers and lights, Procedures in Cosmetic
Dermatology; 2013.
3. Narurkar VA. Dermatology Clinics. Cosmetic Dermatology. Ablative and
Fractional Ablative Lasers. 2009.
4. Pfenninger JL, Stulberg DL. Dermatologic and Cosmetic Procedures in
Office Practice. Usatine RP; 2012.
Bibliography
1. Duffy K, Grossman D. The Dysplastic nevus. From Historical perspective to
management in the modern era. JAAD 2012;67;1-30.
2. Karn D, KCS, Amatya A, Razouria EA, Timalsina M, Suwal A. Q-Switched
neodymium-doped yttrium aluminum garnet laser therapy for pigmented
skin lesions: Efficacy and safety. Kathmandu Univ Med J (KUMJ). 2012 AprJun;10(38):46-50.
3. Lee JB, Chung WG, Kwahck H, Lee KH. Focal treatment of acne scars with
trichloroacetic acid: Chemical reconstruction of skin scars method. Dermatol
Surg. 2002 Nov;28(11):1017-21.
concept for cutaneous remodeling using microscopic patterns of thermal
injury.Laser Surg Med. 2004;34:426-8.
5. Ros EV, Yashar S, Michael N, et al. Tattoo darkening and non-response after laser
treatment: A possible for titanium dioxide Arch Dermatol. 2001;37;33-7.
6. Sardana K, Garg VK, Bansal S, Goel K. A promising split-lesion technique for
rapid tattoo removal using a novel sequential approach of a single sitting of
pulsed CO2 followed by Q-switched Nd: YAG laser (1064 nm). J Cosmet Dermatol.
2013 Dec;12(4):296-305.
7. Weiss ET, Geronemus RG. Combining fractional resurfacing and Q-switched
ruby laser for tattoo removal. Dermatol Surg.2011;37(1):97-9.
Chapter
16
Medicolegal Aspects of Lasers in

Dermatological Practice
Anil Aggrawal, Kabir Sardana
Introduction
The use of high energy light sources [laser, intense pulsed light (IPL)] is a
booming industry. Lasers were introduced in the specialty of dermatology
in the mid-1960s. Since then, their wide acceptance and use provide striking
evidence of their extraordinary ability to treat, precisely and effectively, a
number of skin diseases that were previously incapable of being managed
by other medical or surgical methods. Continued evolutionary changes in
both the laser IPL technology and the understanding of the mechanisms
involved in the lasertissue interaction have improved the precision with
which cutaneous laser surgery can be performed and have also increased the
indications for it.
Typical complications
Laser and intense pulsed light (IPL) treatments are, however, not without
their hazards, especially at the hands of a non-specialist, as has become the
trend lately. Typical complications arising from laser and IPL treatments
are allergic reactions (due to unknown tattoo inks), blistering, burning,
color changes (with removal of permanent make-up), contact dermatitis
(after hematogeneous dissemination of the allergens), crusts, folliculitis,
hypertrophic scarring/keloids, localized herpes virus infections, loss of
pigmentation/hyperpigmentation (depending on laser/IPL setting, skin
type, and preinterventional or postinterventional sun exposure), paradoxical
hair growth (especially with IPL technology) and pruritus. The biggest
problems are the treatment of pigmented lesions of uncertain benign/
malignant nature without prior diagnosis or histological controls, which
often leads to the appearance of an atypical postoperative recurrent nevus
or pseudomelanoma. Sometimes, amelanotic melanomas may be allowed to
progress without detection and may even metastasize.
Laser burns is another injury which may occur during hair removal.
Although usually safe and well tolerated, with the widespread use unexpected
side effects can be seen. In recent years, a new laser technology has been
introduced to aid in pain and other side effects in laser applications. Diode
laser systems are produced for this technology. The major disadvantage with
this laser is the gel application during procedure. Epidermal burn reactions
can occur due to accumulated debris on the guide (Kacar SD).
A number of laser specific complications are detailed in a separate chapter
and needless to say, the patient should be told about the complications and
the course of the sequelae in advance (Table 16.1).
A list of conditions for which litigation was initiated in a study (Jalian HR)
is listed in Table 16.2.
It is not surprising that as laser hair removal is the most common out
sourced procedure, it is the most common cause of litigation. Apart from that,
note that in some cases using the laser for indications that are better treated
by other means can be a valid cause for litigation. The classic examples are
psoriasis and vitiligo. For both, these the excimer laser/light are used which
are in no way superior to other forms of therapy, including phototherapy. If
not charged (as in certain institutions), it may not be an issue, but if charged,
can be a recipe for trouble. Nonsurgical sculpting and tightening are classic
examples of indications where there is a mismatch of expectations and
results, unless patients are counseled well in advance.
Who is qualified to do Laser Surgery?

This question is often asked, especially as the cosmetic laser trend continues to
grow, a number of unqualified practitioners have started doing laser cosmetic
procedures. Physicians are also increasingly using physician extenders (PE)
to assist them with such procedures. A physician extender [most commonly
a nurse practitioner or physician assistant] is a health care provider who is
not a physician but who performs medical activities typically performed by
a physician. Without appropriate supervision and training one can expect
Table 16.1 Injuries sustained because of laser surgery (Jalian HR, et al.)
Burns
Scars
Pigmentation
Disfigurement
Emotional distress
Physical suffering
Erythema
Diminished quality of life
Ulceration
Embarrassment
Eye injury
Death
Disability
Infection
Table 16.2 Laser procedures performed resulting in litigation (Jalian HR, et al.)
Hair removal
Rejuvenationa
Vascular
Leg veins
Tattoo
Neoplasm
Scar
Pigmentary disorder
Pigmented lesion
Others *
* These cases included 6 cases in which the specifics of the procedure were not disclosed, 2
cases related to fat removal, 1 case of skin tightening, and 1 case of psoriasis treatment.
Medicolegal Aspects of Lasers in Dermatological Practice 443
a higher incidence of complications for these nonphysicians (Goldberg). At

many places, most notably wellness facilities, cosmetology institutes, and hair
and tattoo studios, PEs are employed solely, without any supervision by a
trained dermatologist. The underlying legal premise supporting this situation
is that these practitioners are not treating disease. Thus, there is no need for
a diagnosis by a physician, and procedures may be performed by trained
laypersons.
While The American Society for Lasers in Medicine and Surgery, American
Academy of Dermatology, and the American Society for Dermatologic
Surgery have all developed guidelines for PE using lasers in the dermatologic
and cosmetic laser setting, though corresponding Indian societies have
failed to formulate similar guidelines. In the US, according to most guidelines
a PE, where allowed by state law to do laser treatments is required to have
a supervising physician on site and immediately available while the laser
procedure is being performed.
Since lasers may have untoward effects on the body if incorrectly used, only
those persons are legally allowed to use lasers who are qualified in medicine
and surgery, i.e. who hold a proper MBBS degree from an MCI recognized
medical college. Section 27 of The Delhi Medical Council Act, 1997 deals with
False assumption of Medical Practitioner or Practitioner under this Act to be
an offence and states, Any person who falsely assumes that he is a medical
practitioner and practices the modern scientific system of medicine, shall be
punishable with rigorous imprisonment which may extend up to three years
or with fine which may extend up to Rs. 20,000 or with both.
A study by Hammes S, et al. found that the following complications
occurred, with laser procedures performed by medical laypersons: 81.4%
pigmentation changes, 25.6% scars, 14% textural changes, and 4.6% incorrect
information. The sources of error were the following: 62.8% excessively high
energy, 39.5% wrong device for the indication, 20.9% treatment of patients
with darker skin or marked tanning, 7% no cooling, and 4.6% incorrect
information.
Vicarious Liability
A qualified medical practitioner, however, may ask a PE to assist him in laser
surgery. In such cases, the medical practitioner would be liable for all damages
(even if actually committed by PE) under the doctrine of vicarious liability
(syn., vicarious responsibility). It simply means that a person A is liable for
the wrongful acts or omissions of B, if B was under As control. It arises
under the principle of respondeat superior, which holds that the employer
is responsible not only for his own negligence but also for the negligence of
his employees, if such acts occur in the course of the employment and within
its scope. It is also sometimes known as captain of the ship doctrine. As
stated above, this doctrine becomes applicable when the superior had the
right, ability or duty to control the activities of a violator.
Civil and Criminal Negligence

Though cases in consumer forums are common against laser clinics to the
best of our knowledge criminal cases are not usually filed. But we will dwell
on this aspect as the difference between the two depends largely on how the
police interprets the same (Flow chart 16.1).
Flow chart 16.1: Civil and criminal negligence. Action along the dotted line
generally does not occur, but is possible
There is no absolute or watertight differentiation between cases of civil

negligence and criminal negligence. If a patient decides to go to a civil court or
consumer forum to ask for compensation, it is called civil negligence. However,
if the harm caused to the patient is so great (e.g. death) that he decides to
report the matter to police instead, it becomes a case of criminal negligence.
A patient can simultaneously sue the doctor in a civil court and can lodge
a complaint with the police also. Thus, the same case would be fought in
both civil and criminal courts. In such a case, the same negligent action of
the doctor would be civil as well as criminal in nature. The differentiation
between the two, thus, depends on patients action (Flow chart 16.1 and Table
16.3). Also, it is important to understand the difference between negligence
and misconduct (Table 16.3).
Components of Medical Negligence

For a case of medical negligence to be established, the following components
must be present (4Ds). These are the components required for civil
compensation. For criminal charges they do not apply (e.g. Section 336 07 IPC
is applicable, even if no damage occurs).
Duty
The doctor begins to owe a duty towards a patient (i) as soon as he agrees to
treat him (ii) when he is in emergency (S12(2) Clinical Establishments Act
2010). A doctorpatient relationship between the doctor and the patient is
established at that point in time. Doctorpatient relationship is not formed
Table 16.3 Differences between professional negligence and professional
misconduct
Trait
Professional negligence
Professional misconduct (syn. Infamous

conduct, ethical negligence, ethical malpraxis)
Offence
Absence of reasonable care

and skill in the treatment of
patient
No absence of care and skill, but the doctor did

not adhere to the ethical standards befitting a
doctor
Duty of care
towards the
patient
The doctor must have a

duty towards his patient,
which he neglected
No such duty is necessary. Doctor may be

accused of professional misconduct even in
the absence of such duty, e.g. dichotomy, or
when he puts up an unusually large sign board
Damage to
the patient
Must be present
Need not be present
Trial by
Civil or Criminal Court
Medical Council of India or State Medical

Councils
Punishment
Imprisonment or fine
Warning or erasure of name from the medical

register
Appeal
In higher court
To State or Central Governments
when patient is not in emergency, and the doctor did not agree to treat the
patient.
Remember in all laser cases, if the doctor initiates treatment, the duty is
automatically assigned.
Dereliction of Duty
Once the presence of duty has been established, there has to be a dereliction
of duty on the part of the doctor, i.e. the doctor should have been negligent in
performing his duties towards the patient.
The interpretation is open to debate but if due consent is taken, checklist
followed and patient instructions given in the Appendix of the book this is
difficult to prove !
Damage
1. The damage must occur as a result of dereliction, and it must be
foreseeable.
2. Even if doctor is negligent, patient cannot sue him for compensation,
if no damage has occurred. He can however be sued criminally u/s 336
IPC (Flow chart. 16.1).
3. Some examples of possible damages are as follows:

i. Aggravationof a preexisting condition (Paradoxical hypertrichosis
with hair removal lasers).

ii. Diminishing patients chances of recovery.

iii. Expenses incurrede.g. hospital and medicine expenses, special
diet and of course lasers !
iv.
Pain and sufferingcausing either physical or mental
[embarrassment, fright, humiliation] pain or increasing it.

v. Loss of earningdue to absence from work (may be the case if a
resurfacing is done, which is not commonly done nowadays.

vi. Loss of potency.

vii. Prolonging the illness.

viii. Reduced enjoyment of life, e.g. loss of a limb or sense.

ix. Reduction in expectation of life.

x. Death.
Direct Causation
1. Damage must result directly from dereliction (proximate cause), and
not from any other cause.
2. Proximate cause refers to a cause, which in natural and continuous
sequence, unbroken by any efficient intervening cause, produces the
injury, and without which the injury would not have occurred. It may also
be conceived of as a series of falling dominoes. If the final domino
[damage] can logically fall by pushing the first domino [dereliction],

the push is the proximate cause [direct causation] of fall of final
domino.
There is a defense of Novus actus interveniens, which is based upon
lack of this component. It refers to a situation, where the doctor has been
negligent, but a completely unexpected and unforeseen act happened, which
further worsened the patients condition. The new act intervening should be
completely unexpected and unforeseen. Sometimes, referred to as an Act
of God. It must break the natural chain of causation between the act of
negligence and the resulting damage (Fig. 16.1A and B). Thus, injury no
more remains a proximate cause of doctors negligence. This defence is not
available in criminal negligence or criminal activity.
Some examples below would help understand each component above:
Example 1 (Duty): Patient comes to a doctor for treatment of keloid by laser.
Doctor demands his professional fee. Patient is not able to give. Doctor refuses
treatment. Patient does not take treatment from elsewhere. After some time
keloid becomes infected. Patient suffers injury. Patient cannot sue doctor,
because no duty was established.
Example 2 (Dereliction): Patient comes to a doctor for treatment of
hypertrophic scars by laser. Doctor treats him with correct laser, but
hypertrophic scars remains. End result is that the patient is not treated.
Patient cannot sue, as there was no dereliction on the part of doctor.
Example 3 (Damage): Patient comes to doctor for facial laser resurfacing.
Doctor agrees to treat (duty established). Doctor uses lasers carelessly so
patient develops blistering and burning (damage). Patient can sue doctor.
If though despite doctor using lasers carelessly, patient does not suffer any
damage, patient cannot sue doctor.
Example 4 (Direct causation): Patient comes to doctor for laser removal
of tattoo. Doctor agrees to treat him (duty is established). Doctor fails to use
Figs 16.1A and B: Concept of (A) proximate cause and (B) novus actus interveniens
the right laser (dereliction occurs) Tattoo is not removed. After ten years,
the tattoo becomes cancerous due to nature of dye within (damage occurs).
Patient sues first doctor for not using the right laser. He cannot succeed
because although, there was duty, dereliction and even damage, but
damage was not a direct result of doctors dereliction.
This of course is open to debate, as it is theorized that Azo dyes used in
tattoo can potentially cause psudolymphomas, though whether laser can
aggravate this is unknown. Again removal of moles (common acquired
melanocytic nevi) by lasers, have been linked though controversially to
malignancies. This is almost unheard in India, but is reported in world
literature.
How to prevent malpractice claims

A interesting insight into the types of complaints entertained in litigations
in USA is given in Table 16.4. A few of them that can be of concern in India
include deceptive trade practices, failure to properly hire, train, or supervise
staff, failure to select appropriate laser and/or setting, not trained and/or
certified to operate laser and failure to properly calibrate and maintain lasers.
We are adding one more to this list, which can be a valid cause of a civil
suit, using non US FDA /CE approved lasers. With no certification in India,
these are the certifications essential, which I daresay do not exist for most
lasers sold.
Thus prevention is better than facing malpractice claims. Following
simple rules will help prevent malpractice claims to a great extent.
Table 16.4 Common complaints in litigations in laser cases

Cause of action
Specific allegations
Lack of informed consent
Failure to properly hire, train, or supervise staff
Fraud
Failure to properly perform treatment and/or operate laser
Loss of consortium
Failure to select appropriate laser and/or setting
Assault/battery
Failure to warn and/or inform of risk
Strict products liability
Failure to conduct test spot
Breach of contract
Not trained and/or certified to operate laser
Infliction of emotional distress
Failure to recognize and/or treat injury
Negligent misrepresentation
Failure to properly calibrate laser
Gross negligence
Failure to maintain laser
Recklessness
Failure to biopsy
Deceptive trade practices
Failure to supply goggles
Patient Information and Documentation

Many malpractice claims arise due to lack of patient information, or sometimes
inflated claims. Physicians should ensure that they themselves inform the
patients and do not delegate the responsibility to nurses or paramedical staff.
Informed consent must also be taken by dermatologists themselves, and it
must be written. A patients signature on a preprinted consent form, which has
not been preceded by a discussion with the physician does not grant doctors
free rein, and in the event of a legal dispute, such a form can be declared
invalid. The optimal procedure consists of a thorough discussion, after which
the patient is given a consent form to which handwritten additions are made
as necessary. Detailed information should be provided about the diagnosis;
the nature, extent, and process involved in the planned treatment; potential
short- and long-term adverse effects; possible alternative treatments; and
the costs to be expected. Rare concomitant effects, adverse effects, and risks
should also be discussed if they are typical for the procedure in question.
Treatment should not be performed on the same day the discussion is
held; patients should have the chance to make a decision without being
pressured for time and without being affected by the psychological burden
of the procedure awaiting them. Patient documentation should include
information about discussions between the physician and patient, the
preoperative diagnosis and histologic findings (to whatever degree present
or necessary), the indication for laser treatment, test treatments, the kind of
anesthesiology, the kind of laser and parameters of application, the results of
treatment, and any concomitant reactions, adverse effects, and complications
(intra- or postoperative, infections, late complications, etc.). Especially in
the case of cosmetic procedures, additional photographic documentation is
recommended. This is relevant from a forensic perspective, as well as being
useful if the patient should question the success of the treatment.
Some clinicians prefer to write a risk, benefit and alternatives (RBA) note
together with a written informed consent.
It is wise to seek informed consent for each type of laser that is operated
by the physician. Each laser system functions in a unique fashion. The same
laser created by various competitors may differ in terms of treatment settings
and potential side effects. For this reason, establishing a relationship with the
laser company for support is advantageous for the physician. Furthermore,
ensuring that the medical device is FDA approved for patient therapy could
minimize liability.
Though a detailed consent form is given in the Appendix of the book, we
are detailing the essentials in a conset form, which can be remembered by the
mnemonic LASER (Abel Torres, et al.) (Table 16.5).

Table 16.5 Ideal components of a consent form
Liability
waiver
A patient needs to be told that Laser procedures are not reimbursable and
no other procedure will be shown in lieue of it !
Anesthesia
type
There are risks associated with all types of anesthesia, including topical (see
Chapter on Drugs)
Surveillance
Observations, outcomes and side effects on

the postoperative record documents treatment
course in the best interest of the patient
Expectations
A no guarantee clause should be emphasized as no indications has definite

cures
Revocation of
consent
Offer the option of letting the patient refuse

treatment at any time especially if it alters
outcome
Snapshot
Photogarphs are to be taken specifically for documenting results and are

confidential unless specified
Training
Malpractice claims are mostly due to professional errors, which in turn, are
due to lack of training and experience. Thus, training must be strengthened.
The ideal method of ensuring thorough training, is to establish teaching
centers for laser treatment in qualified, certified offices or clinics. In such
institutions, guidelines should be taught on topics including didactic,
hands-on, and laser-specific clinical techniques. Standards of practice are
sometimes handled as if they are top secret information. This should not be
done; instead, they should be officially instructed and published. In the US
and some other developed nations an oral and written examination is a must
for every dermatologist in practice. It serves as a rational and fair strategy
to assess theoretical and practical proficiency objectively after a defined
period of continuing education is completed. Sadly, in India, there is no such
program. If such programs are started and widely followed, these may serve
to reduce professional errors, and in turn, malpractice claims.
In case a physician is using lasers in dermatology, he must have
dermatologic training in addition to laser-specific training.
Do not Make Unrealistic Claims

It has been seen that many malpractice claims originate as a result of failed
patient expectations, which in the first place are raised very high almost to
unrealistic levels. Some examples are removal of 8090 % of the hair in 23
sessions or 1064 nm Nd:YAG laser is superbly suited for removing moles
and dark hyperpigmentation spots. Experience has shown that whenever
the patient has been given realistic assurances, the incidence of malpractice
claims remains low.
Handling the Press

Proliferation of print and electronic media in India, has caused journalists to
look around for cases to feed their 24 7 news channels. Medical malpractice
cases, being inherently potential TRP enhancers are among the most hotly
pursued stories by print and TV journalists. If for example, a patient has
been injured by laser treatment, the journalist would approach some top
laser practitioners and would like to know their views on it. It would be
wise for laser practitioners not to criticize their colleagues for 2 reasonsit
is unethical to pass derogatory remarks against a colleague, and secondly,
the case may be in court and any comments may cause an unduly adverse
outcome in the case. The results of some surveys indicate that doctors need
to be trained to handle the press.
How to handle a malpractice claim if it does occur?

Involvement in a lawsuit as a defendant may be in a civil or criminal case.
Experience has shown that a vast majority of medical malpractice cases in
India are civil cases, which is good news for doctors, because at most they
would entail payment of damages and not imprisonment. A minority of cases
[generally those in which death has occurred], are fought in the criminal
court, in which there may be imprisonment to the doctor. However there is
no bar for a patient to go to a criminal court even for minor injuries [s 337 IPC]
or most surprisingly even if no injury has occurred [s 336 IPC]. The latter case
may be unbelievable to some, but there is a distinct theoretical possibility of
this occurring. The analogy is fast, reckless driving through a city. Even if no
one is injured, the driver is still liable, because he could have caused injury
by engaging in such a rash and negligent act. Similarly, if a doctor is rash
and negligent in using lasers, and if a patient has ample proof of it, he can
approach the court, even if no injury has occurred to him. Thankfully such
situations are extremely rare.
It must be noted that a patient can sue for compensation in a consumer
court only if he has paid fees to the doctor. If no professional fees has been
paid, the patient cannot invoke a consumer court, but he can still approach a
civil court under tort law. Generally, such cases drag on for years in India and
are a cause of worry for doctors.
The most worrying cases are criminal cases, in which the patient
complains to the police, and the police lodges a case against the doctor. In
laser applications of dermatology, such cases are likely to be extremely rare,
simply because grave laser injuries are virtually unknown, and as already
stated, the patient generally would refrain from going to the police until and
unless the injury is very grave and debilitating.
Countersuits
One way to deal with a suit is filing a countersuit. A countersuit is an action
brought by a physician against the patient (the plaintiff in the original
malpractice action), as a retaliation strategy. It is based on the maxim, attack
is the best form of defense. This strategy works best, if the laser practitioner
is sure that the malpractice claim is malafide and unjust. The countersuit
movement began in the mid-1970s with enthusiastic support by the medical
profession in response to the dramatic rise in medical malpractice suits,
many of which were perceived as lacking substantial merit. It must be
remembered that courts would not taken this approach very positively if the
laser practitioner was actually at fault. They have rejected most countersuits,
which were filed merely as an attacking policy. Courts follow a public policy
interest in ensuring that injured parties have free and open access to the
judicial system
Alternative Dispute Resolution (ADR)

A far simpler and better approach is alternative dispute resolution or ADR.
It refers to dispute resolution techniques that help plaintiffs and defendants
resolve conflicts outside of the courtroom. It is advantageous to both patients
and doctors. Patient can save time from litigation and focus efforts on
healing. Money saved on lawyers and court goes directly to the patient.
Many hospitals in the US have embraced early apology programs, where
physicians and hospital administrators reach out to the injured patient and
express sympathy about the adverse event. This protects the natural doctor
patient relationship as well as encourages dialogue.
Mediation and Arbitration

The most popular ADR techniques are mediation and arbitration. They
differ in both their binding nature and their formality. Mediation is simple
negotiation that is aided by an impartial mediator. It is nonbinding, meaning
that if a settlement cannot be reached, the plaintiff may pursue his claim in
court. Arbitration is more court-like, with an arbiter hearing both sides
much like a judge would. Similarly, there are rules for how and when to talk,
and how to present evidence. Most importantly, it is binding, meaning that
the judgment of the arbiter is final and litigation is not an option.
Mediation
Mediation has had excellent success where implemented, both in terms of
cost-containment and satisfaction for both parties. From the plaintiffs
perspective, mediation offers more flexibility than litigation, which only
offers money as a remedy. Experience has shown that patients who come
for laser cosmetic surgery are, by and large from upper echelons of society
and often do not engage in litigation for money. Many sue for nonmonetary
reasons, such as the desire for disclosure of information or the desire to
hear an apology or explanation of what went wrong. In the US, for example,
rather than just receiving money, some plaintiffs wish for a scholarship to
be established in their familys name, or like their deceaseds story told
to incoming nurses or medical students to help prevent similar adverse
events in the future. Similar trends are appearing among the rich patients in
India. For these reasons mediation often suits plaintiffs needs better. Nonmonetary aspects like the ones mentioned above are withheld in a litigious
environment.
Arbitration
Arbitration is different from mediation. It is more acrimonious and expensive,
being more trial-like than mediation. It is longer and more expensive than
mediation, but much shorter and less expensive than court trials. Like court
trials, arbitration can only offer money as a form of redress, eliminating the
more creative and satisfying solutions offered in mediation.
Pretreatment Arbitration Agreement

Laser practitioners may want to undergo a pretreatment arbitration
agreement. Under this arrangement, patients agree to arbitration as a
condition of being seen in the first place. This has become an increasingly
popular form of arbitration in the US. However, it suffers from the great
disadvantage that it is awkward to discuss adversarial postures during the
initial physicianpatient visit itself.
Benefits of Mediation and Arbitration

Benefits of mediation and arbitration are almost 100% avoidance of litigation.
Thus, these are very appealing to everyone alikedoctor, patient and even
the insurer, as even a successful defense can cost a lot. There is a private and
informal setting outside of the courtroom. In case of arbitration, the decision
of arbiter is binding and there are no appeals process. It occurs as scheduled
and without delay, unlike many court cases. Damage awards tend to be more
predictable and usually are more in line with settlement values than those
afforded by court trials.
Conclusion
A detailed patient information sheets, consent form and postprocedure
check list has been given in the Appendix of the book which can help to avoid
unnecessary medicolegal issues.
Laser cosmetic surgery can legally be done only by a person qualified in

modern medicine and surgery. Any other person engaging in laser cosmetic
surgery can only do so under supervision of a qualified dermatologist. If
dermatologist is sure, the malpractice suit by the patient is malafide, he can
respond by filing a countersuit. If on the other hand, he knows he has been
negligent, the best approach is mediation and arbitration.
Bibliography
1. Abel Torres, Tejas Desai, Alpesh Desai, and William Kirby. Medicolegal Issues
(Documentation/Informed Consent). K. Nouri (ed.), Lasers in Dermatology
and Medicine, DOI: 10.1007/978-0-85729-281-0_31, Springer-Verlag London
Limited 2011
2. Goldberg DJ. Laser physician legal responsibility for physician extender
treatments. Lasers Surg Med. 2005;37(2):105-7.
3. Greve B, Raulin C. Professional errors caused by lasers and intense pulsedlight
technology in dermatology and aesthetic medicine: preventive strategies and
case studies. Dermatol Surg. 2002;28(2):156-61.
4. Hammes S, Karsai S, Metelmann HR, Pohl L, Kaiser K, Park BH, Raulin C.Treatment
errors resulting from use of lasers and IPL by medical laypersons:results of a
nationwide survey. J Dtsch Dermatol Ges. 2013;11(2):149-56.
5. Jalian HR, Jalian CA, Avram MM. Common causes of injury and legal action
inlaser surgery. JAMA Dermatol. 2013;149(2):188-93.
6. Jalian HR, Jalian CA, Avram MM. Increased Risk of Litigation Associated With
Laser Surgery by Nonphysician Operators. JAMA Dermatol. 2013 Oct 16.
doi:10.1001/jamadermatol.2013.7117.
7. Kacar SD, Ozuguz P, Demir M, Karaca S. An uncommon cause of laser burns: The
problem may be the use of gel. J Cosmet Laser Ther. 2014 Feb 10. [Epub ahead of
print]
Chapter
17
Complications and their Management

Kabir Sardana
Introduction
There are very few studies that examine complications across different lasers.
Most studies are focused on a particular device.
A recent study (Zachary Zelickson) that used the Manufacturer and user
facility device experience (MAUDE) database from 2006 to 2011 found that
the most common cosmetic laser treatments with complications was hair
removal. Thirty percent of laser surgery complications were due to user error,
20% device malfunction, and 4% due to patient error.
Common Devices and their complications

Lumenis had the most (204) complications, followed by Candela (66), and
Rhytec (65). The list of commonly reported device causing side-effects
are given in Table 17.1. Intense pulsed light (IPL) devices had the most
Table 17.1 A summary of complications of lasers *
Device
Complications reported
IPL
Plasma
RF monopolar
CO2
810 diode
1,064 nm Nd:YAG
755 nm alexandrite laser
NA fractional (NAFR)
Pulsed dye laser
Nd:YAG
142
65
59
57
39
37
29
21
15
6
Ablative fractional
RF (fractional, needle, suction)
3
2
Thulium
Fractional CO2
USG
*(MAUDE): US Food and Drug Administration (FDA) manufacturer and user facility device
experience (Zachary Zelickson et al)
(142) complications, followed by plasma radiofrequency (RF) (65), and RF

monopolar devices (59). The ve most common complications were burns
(36%), scarring (19.4%), pigmentation damage (8.5%), blistering (2.4%), and
infection (8%). In darker skin types, PIH is by far the most important sideeffect.
A list of device specific complications is given in Table 17.2. The IPL and
the RF report the highest complications while the fractional devices and Qsw
lasers are safer. Notably the Er:YAG has no complications reported which
makes it the ideal laser in Indian skin type for ablative procedures.
With little by way of reporting, there is no data base in India of the side
effects, but the incidence would largely reflect the studies published.
Overview of Common Complications

Pain
This is a universal feature of all laser procedures and a certain degree of
interindividual variation is seen.
Prevention and Treatment

Cooling devices have played a large role in minimizing pain and optimizing
treatment of specic lesions and are crucial in pigmented skin.
Table 17.2 A list of common side effects associated with common laser devices*
Device
Common device complications
Intense pulsed light
Burn
Blister
Scar
Pigmentation
Plasma Resurfacing
Infection
Scar
Burn
Pigmentation
Radiofrequency monopolar
Burn
Blister
Scar
Pigmentation
Carbon dioxide
Scar
Burn
Pigmentation
810 diode
Burn
Pigmentation
Scar
Blister
*(MAUDE): US Food and Drug Administration (FDA) Manufacturer and User Facility Device
Experience
Complications and their Management 457
The use of anesthesia is important, though in some, it may not be required.

For fractional lasers we have found that pretreatment icepack cooling is
adequate for most patients. This also has the added advantage of a modicum
of cost saving for the patient. Some lasers (the PDL) often do not require pretreatment anesthesia. In some case, infiltration anesthesia may be required.
One protocol includes topical lidocaine/tetracaine application with
another approach being a combination of hot compresses, topical lidocaine
and oral anxiolytics (vicodin, diazepam or ketorolac) for resurfacing
procedures.
Erythema and Edema

They are both expected to occur and in fractional lasers, they are usually
transient (Fig. 17.1). Some reasons for excessive edema include, excess pulse
stacking or passes, treatment of periocular areas, and use of high energy
settings. Concomitant use of tretinoin is also a predisposing factor.

A simple method to resolve this is the use of post-treatment cold-packs, head
elevation and short-term use of topical steroids (Fucidin HTM).
Crusting and Vesiculation

Crusting and vesiculation are manifestations of epidermal damage in certain
indications (Qsw Lasers). It is bound to occur and the patient should be
Fig. 17.1: Edema and erythema seen immediately after Er:Glass therapy for scars.
Mild and Reversible. Icepack suffices in most cases. A mild steroid can be used for 12
days to prevent PIH
forewarned about it (Fig. 17.2). In fractional lasers, a certain degree of posttherapy areal density marks are also evident, which resolve in 35 days
(Fig.17.3).

1. In most non-ablative procedures, we usually give topical aloe vera
gel (JulaTM/Aloekem 75TM) or a bland non-sensitizing moisturizer
Fig. 17.2: A case of segmental lentigines post Qsw Nd:YAG (day 2). Crusting is seen,
and a bland moisturizer (petroleum jelly, CetaphilTM cream, JulaTM gel) is given till
the crust falls off. Judicous sunscreen use is advised
Fig. 17.3: Crusting seen corresponding to the MTZ patterns of a fractional Er:Glass
(Lux Palomar). Mild and reversible. Sunscreen with a topical non-HQ/tretinoin
cream( MelaglowTM) is used for 14 days
(CetaphilTM/PhysiogelTM) with a topical steroid (Fucidin HTM) and advise

the patient not to remove the crust manually. Saline compresses are
advised which help in rapid removal of the crust.
2. For ablative procedures, a petrolatum based preparation is advisable
(EpicreamTM, EucerinTM, SecaliaTM) with the use of a non-sensitizing
antibiotic (Fucidin).
3. Sunscreen (physical block) is advised till complete healing.
Purpura
Purpura results when there is damage to small vessels and subsequent
extravasation of red blood cells. It is common following treatment with the
PDL and is, in fact, a therapeutic endpoint when treating certain vascular
lesions with short pulse durations and high uences (so-called purpuramode).
In case IPL is used for PWS, a bruise-like appearance frequently occurs
which can take 56 weeks to subside (Fig. 17.4) and is part of the therapeutic
reoponse.

All patients should be off anti-coagulant and anti-platelet agents at least 34
days prior to the planned procedure, which should be discussed with the
physician.
Lowering uence and increasing pulse duration (in the PDL) can help
minimize purpura.
As port wine stains and hemangiomas, cannot be effectively treated with
non-purpuric parameters, patients should be aware of the potential of downtime.
Fig. 17.4: A case of PWS treated with a IPL. Note the bruise-like darkening visible
that precedes resolution
Dyspigmentation/Post-inflammatory Hyperpigmentation (PIH)

Dyspigmentation can be transient or permanent and takes on two forms:
hyper-or hypopigmentation. Hyperpigmentation is a common manifestation
of post-inammatory change in the tissue. It generally appears 34 weeks
postoperatively and spontaneously resolves over the next several months,
though permanent hyperpigmentation can occur.
Hypopigmentation occurs when lasers inadvertently target melanin. QS
lasers and IPL often cause a transient hypopigmentation during treatment
due to the absorption of light by melanin and subsequent injury to individual
melanosomes. Rarely, permanent hypopigmentation can appear 612
months after resurfacing procedures (delayed hypopigmentation) due to
thermal injury (Fig. 17.5).
In general, patients with dark or tanned skin have a greater risk of
dyspigmentation. For such patients, treatment with lasers with shallower
depths of penetration (i.e. shorter wavelengths and smaller spot sizes) confers
greater injury to epidermal melanocytes and should be avoided.

PIH
1. Lasers with longer wavelengths and larger spot sizes should be used as
the depth of penetration will be greater and risk of injury to epidermal
melanocytes smaller. As a rule, a test spot and lower uences should be
used in pigmented skin.
Fig. 17.5: A case of Beckers nevus treated with IPL. Note the hypopigmentation
corresponding to the footprint of the probe
2. Though preoperative sunscreen and alpha-hydroxy acids or bleaching

agents combined with a topical steroid may help, this has never been
satisfactorily been proved in any study, to prevent PIH. In fact, a
prospective study of 100 patients undergoing CO2 laser resurfacing
found no signicant difference in the incidence of post-inammatory
hyperpigmentation between patients pretreated 2 weeks with glycolic
acid cream or combination tretinoin/hydroquinone creams versus no
treatment (West TB).
3. In most non-ablative procedures, we usually follow the following
schedule:

a. First 7 days, a combination of aloevera (Aloekem 75TM/JulaTM gel) in
the morning with fucidin cream at night.

b. Second 7 days continue the aloe vera and add a non-HQ/tretinoin
cream at night. We prefer MelaglowTM as it inhibits two stages of
melanogenesis. (4% niacinamide, 0.2% soy isoflavanoid and 0.1%
glabridin and 2% kojic acid). Another option often employed is a
steroid antibiotic combination. Here, the relative potency must be
understood and thus Fucidin H or Fucibet is better than Flutibact.
This is as Flutibact ointment as per the American Classification
contains fluticasone propionate ointment 0.005% which is a Class
3 steroids as opposed to betamethasone valerate cream (class
5) which is a part of Fucibet and Hydrocortisone (class 6) which
is a component of Fucidin H. It is inadvisable to use gentamicin/
neomycin due to their allergenic potential or mupironic acid as it
may lead to resistance.

c. After 21 days, we stop the steroid and continue the use of the
depigmenting cream.

d. A physical block sunscreen is preferred for the duration of post
treatment care.
Though we have discussed the demerits of using laser toning previously,
it, must be reemphasized that in Indian skin, it can cause perilous pigmentary
alterations (Fig. 17.6)
Hypopigmentation
This is seen either while using a Q-switched lasers (Fig. 17.6) or as a
consequence of overuse of topical steroids. For hypopigmentation, use of
topical PUVA (oxsoralen and UVA light therapy) has been used to induce
melanogenesis, so has been phototherapy (Mysore V). It is this authors
opinion that the use of laser toning for melasma is best avoided as it can lead
to unfortunate pigmentary alterations (Fig. 17.6).
In all cases, a test spot is a very useful tool as seen in the patient in
Figure 17.7. Though the pigmentation resolved in this patient, it is a safe
practice to forewarn the patient about the pigmentary sequelae.
Fig. 17.6: A case of melasma treated with laser toning (Qsw Nd:YAG). Note the
depigmentation and darkening of the melasma (Courtesy: Dr Shilpa Garg )
Fig. 17.7: A Beckers nevus, test spot with a Er:YAG laser. Note the hypopigmentation
Scarring
Scarring is nowadays rare as it is seen mostly with ablative procedures which
are not done so commonly nowadays. The terminology in the literature can
be confusing as some texts describe textural change where there is a change
in the contour of the skin, truly differentiating it from a permanent scar.
Causes
The most likely cause of scar formation following laser treatment is excessive
thermal injury to the treated tissue. Pulse stacking or multiple passes, high
energy uences or inadequate cooling can all precipitate thermal injury.
Selection of an appropriate laser and use of the correct treatment parameters,
for a given indication, is paramount in avoiding excessive tissue damage and
scarring. Patients with a history of recent isotretinoin therapy, keloid scar
formation or radiation therapy may be at increased risk for hypertrophic scar
formation, following resurfacing procedures. Additionally, postoperative
resurfacing complications, such as infection and contact dermatitis, may
also lead to scarring. Treatment of certain anatomical locations, including
the mandible, anterior neck and infraorbital areas are more likely to scar.
Reduced laser parameters are recommended in these areas.

Some signs are useful indicators for impending scarring:
1. Marked erythema or graying of the epidermis during treatment may
indicate signicant damage and the need to discontinue treatment or
adjust parameters.
To avoid this multiple test spots with varying uences and/or pulse
durations can be performed prior to treatment, particularly in patients
with an increased risk of scarring.
2. Any sign of infection should be treated. We often use levofloxacin
750 mg a day before to 4 days after the laser intervention to avoid
such complications. If infection is ruled out, prompt application or
intralesional injection of corticosteroids can halt the progression of
hypertrophic scars.
Intralesional steroids, 5-uorouracil (5-FU) and laser therapy have proved
benecial in the treatment of hypertrophic scars. PDL treatment has been
reported to improve the symptoms, pliability and color and decrease the size
of hypertrophic scars.
Laser specific Complications

Fractional Lasers
The side-effects are mild, reversible and largely minor (Figs 17.1 and 17.3).
Though it is believed that the ablative fractional lasers have more side
effects, this has not been our experience (Sardana K, 2014). A retrospective
evaluation of 961 successive 1,550 nm erbium-doped laser treatments in
patients of various skin phototypes (I-V) was conducted by Graber EM et
al., only 73 treatments (7.6%) resulted in development ofcomplications. The
most frequentcomplicationswere acneiform eruptions (1.87%) and herpes
simplex virus outbreaks (1.77%). Post-inflammatory hyperpigmentation,

which occurred with increased frequency in patients with darker skin
phototypes. Another study on Asian skin, (Vaiyavatjamai P et al) where
the 1550 nm ytterbium/erbium fiber laser was used found side-effects in
only six treatments (3.3%). The most common adverse event was postinflammatory hyperpigmentation (2.2%), while acneiform eruption and
desquamation were reported 0.55%, equally. Although, none of the patients
received herpes prophylaxis, there were no herpes outbreaks.
A summary of the side effects and their management is given in Tables
17.3 and 17.4.
Lasers for Hair Removal

This has been discussed in a previous chapter, thus a brief summary will be
given here.
Hypertrichosis
Several studies have documented paradoxical hypertrichosis following
laser hair removal. This primarily occurs after several treatments have been
performed on the face and neck of female patients with darker skin types.
The mechanism that triggers the conversion of these vellus to terminal
hairs is unknown, but may be related to inammation induced by the laser
therapy itself. Management of this uncommon complication is with further
photoepilation.
Leukotrichia
This is seen when patients are treated with long-pulsed Nd:YAG lasers. These
lasers target melanin and penetrate deep enough to reach the hair follicle.
Table 17.3 Complications reported with fractional lasers
Mild
Prolonged erythema
Acne, milia
Delayed purpura
Superficial erosions
Contact dermatitis
Recall phenomenon
Moderate
Infection
Pigmentary alteration
Anesthesia toxicity
Eruptive keratoacanthomas
Severe
Hypertrophic scarring
Ectropion formation
Disseminated infection

Table 17.4 Complications and their management *
Prolonged erythema (>1 month)
Avoid use of irritating topical cream (HQ/tretinoin)

Apply mild corticosteroid (Fucidin H)
Apply non-steroidal anti-inflammatory agents
(Clindamycin/metronidazole gel)
LED photomodulation
Milia/acne exacerbation (>1 month)
Discontinue occlusive dressings/ointments

It is best to use agents that are non-sticky
(Sebamed Clear gel, CetaphilTM cream)
Physical extraction of milia
Oral antibiotics for acne
Contact/allergic dermatitis
Never use neomycin/gentamicin-based creams

Use non-sensitizing creams (Physiogel)
Topical/oral corticosteroids
Infection (114 days)
Oral antibacterial/antiviral
Topical wound care (Fucidin)
Hyperpigmentation (1 month)
Sunscreen (physical block)

Topical lighteners (MelaglowTM)
Hypopigmentation (upto 6 months)
Excimer laser
Topical photochemotherapy
Hypertrophic scar (1month)
Potent topical corticosteroid

Pulsed dye laser
*Brand names mentioned here are indicative only does not indicate any commercial
affiliations or endorsement
With subtherapeutic uence levels, follicular melanocytes may be destroyed

in the absence of other follicular injury, resulting in leukotrichosis.
Reticulate Erythema
Persistent reticulate erythema has been described in at least 10 patients
following hair removal with the Diode laser (Lapidoth M). Pernio and perhaps
other connective tissue diseases, as well as high energy uences, seem to be
potential risk factors.
Urticarial-like Plaques
Pruritic, urticarial-like plaques have been described following photoepilation. Unlike urticaria, however, lesions may last several days to weeks.
Topical and oral corticosteroids and anti-histamines can be used for
symptomatic relief.
Burns
These are commonly seen with the diode and IPL and with these systems,
a preoperative, intraoperative and postoperative cooling is essential
(Figs 17.8A to C). Also post-treatment, a steroid applications for 35 days is

advisable. In patients with a acne prone skin ice pack cooling for 12 hours
after therapy is another option.
Lasers for Pigmented Lesions

Leukotrichia
Melanin, located in the epidermis, dermis and follicular structures, is the
primary chromophore targeted in the treatment of various pigmented
lesions. Melanocytes within the hair follicle can be destroyed inadvertently
when using high uences and more deeply penetrating, longer wavelengths.
Permanent leukotrichia can result. Limiting the uences and selecting lasers
with shorter wavelengths, if possible, will minimize this complication.
Tissue Splatter and Pinpoint Bleeding

Tissue splatter and pinpoint bleeding are expected side-effects of treatment
with Q-switched lasers. When tissue targets are heated to destructive levels
over nanosecond (Qs) pulse durations, particles can become aerosolized
creating tissue splatter and blood vessels can rupture leading to pinpoint
bleeding and petechiae. Laser treatment through a water-based gel dressing
Figs 17.8A to C: A series of cases with

intraoperative burns and pigmentary
alterations (Courtesy: Dr Anil Ganjoo)
(Fig. 17.9) minimizes tissue splatter and bleeding by acting as a heat sink and
protecting the epidermis (Bernstein EF).
Pigmentary Alterations
In almost all cases, a transient hypopigmentation occurs as the Qsw lasers
can impact on the normal epidermis. Luckily, the pigmentation resolves
spontaneously in a few weeks (Fig. 17.10).
Fig. 17.9: Application of a transparent Tegaderm dressing before tattoo removal. This
prevents tissue splatter but a slightly higher dose is required. The unique advantage is
that this acts as a biological post-laser dressing
Fig. 17.10: A case of nevoid linear hypermelansosis after one week of treatment with
a Qsw Nd:YAG (532 nm). The hypopigmentation is inevitable but transient
Tattoos
Allergic and Photo-allergic Contact Dermatitis
During laser treatment of tattoos, pigment is released from intra- to
extracellular sites exposing these antigens to the immune system. Rarely, a
type-IV hypersensitivity reaction or photoallergic reaction to the components
in the pigment can develop. Cinnabar, found in red tattoo pigment, is the
most common contact allergen, while cadmium, which is found in yellow
tattoo pigment, is the most frequent photoallergen. Those who have a contact
dermatitis to pigment often give a history of pruritus and raised red areas
over their tattoo sites. In photodermatitis, this reaction is heightened when
exposed to sunlight.
Ablative resurfacing procedures can be used for tattoo removal with less
risk of mounting an allergic response. However, a localized allergic reaction
has been reported to become generalized following CO2 laser removal of a
tattoo.
Combustion
Treatment of tattoos that contain combustible material should be avoided.
Sparks and incipient pox-like scars occur after Qs Ruby laser treatment of
a traumatic tattoo. If the composition of the pigment is unknown, a biopsy
and/or test spot should be performed to help elucidate the material.
Paradoxical Tattoo Darkening

Paradoxical darkening of certain tattoo pigments has been reported with
QS laser treatments. The exact mechanism is unknown, but the reduction of
ferric oxide to ferrous oxide may play a role. Titanium dioxide may also be
implicated in paradoxical darkening through a similar mechanism.
Ferrous oxide is found in some red, orange, peach or other skin-colored
pigments and titanium dioxide is found in white pigments, often used alone
or in conjunction with other colors to brighten them. As such, specic
areas of tattoos containing these colors should undergo spot testing prior
to full treatment with a Qs laser. Once paradoxical darkening has occurred,
correction can be difcult. Repeated laser treatments have been successful,
as well as ablative resurfacing procedures.
Lasers for Vascular Lesions

Reticulated Purpura
Purpura is a common, and usually expect side-effect of the PDL. Often a
reticulated pattern of purpura develops after treatment due to the Gaussian
distribution of energy of each laser pulse. Overlapping pulses by 18% can
minimize this complication.
Fig. 17.11: Postoperative view of a syringoma case after pulsed CO2 laser. Note the
hypopigmentation corresponding to the syringoma which tend to persist for 12
months
Ablative Lasers
As full face resurfacing is rarely done the side-effects are hardly reported.
With Er: YAG, almost no side effects are seen. With the CO2 laser, infections,
textural alterations, PIH, and scarring may be seen (Fig. 17.11).
Conclusion
Laser-induced complications are largely preventable, except pigmentary
alterations in pigmented skin. But a simple rule that this author follows is not
to replicate results reported in literature in fair skin types with lasers that have
a short wavelength (Qsw ruby or Alex) as they are most prone to pigmentary
alterations as the epidermal pigment competes with the laser. The triad of,
consent, test spot, and pre-and post-photography are crucial. Methods of
cooling, both device based and extrinsic with a good postoperative care
are essential. A list of check lists and postoperative care is provided in the
Appendix which can obviate and preempt most laser-induced complications.
The consent form provided in the Appendix takes into account most of the
legal possibilities and help to negate any medicolegal issues, if they do
happen.
Bibliography
1. Bernstein EF. Laser treatment of tattoos. Clin Dermatol. 2006;24:43-55.
2. Graber EM, Tanzi EL, Alster TS. Side effects and complications of fractional laser
photothermolysis: Experience with 961 treatments. Dermatol Surg; 2008.

3. Lapidoth M, Sharstein G, Ben Amitai D, et al. Reticulate erythema following
diode laser-assisted hair removal: a new side effect of a common procedure. J
Am Acad Dermatol. 2004;51:774-7. Mar;34(3):301-5; discussion 305-7.
4. Mysore V, Anitha B, Hosthota A. Successful treatment of laser induced
hypopigmentation with narrowband ultraviolet B targeted phototherapy. J Cutan
Aesthet Surg. 2013 Apr;6(2):117-9.
5. Sardana K, Manjhi M, Garg VK, Sagar V. Which type of atrophic acne scar
(Ice-pick, Boxcar, or Rolling) responds to nonablative fractional laser therapy?
Dermatol Surg. 2014 Mar;40(3):288-300.
6. Vaiyavatjamai P, Wattanakrai P. Side effects and complications of fractional
1550-nm erbium fiber laser treatment among Asians. J Cosmet Dermatol. 2011
Dec;10(4):313-6.
7. West TB, Alster TS. Effect of pretreatment on the incidence of hyperpigmentation
following cutaneous CO2 laser resurfacing. Dermatol Surg. 1999;25:15-7.
8. Zelickson Z, Schram S, Zelickson B. Complications in Cosmetic Laser Surgery: A
review of 494 food and drug administration manufacturer and user facility device
experience reports. Dermatol Surg. 2014;15. DOI: 10.1111/dsu.12461.
Chapter
18
New Aspects and

Controversies in Lasers
Kabir Sardana, Rashmi Sarkar
Introduction
Lasers and their applications have over the years gone beyond the simple
application of the principles of selective photothemolysis to novel procedures
and indications to technology modifications. Combinations of lasers,
especially fractional lasers, have resulted in endless possibilities that defy any
meaningful discussion. Unlike drugs where restrictions exist, with lasers there
is little regulation on approaches to therapy. Moreover, little evidence-based
literature exists, possibly as very few objective tools are used for evaluation.
Then there is the issue of results on Western skin, southeast Asian skin and
Indian skin. We feel that not all results are replicable in our skin types.
An assessment of literature is important to apply the knowledge in clinical
practise. Not all studies are applicable to pigmented skin and as the laser
technology has little regulation, it is important to decide how to assess clinical
data. I have used 4 criteria to assess the studies published, these include as
follows:
1. Deriving from the Cochrane data base criterion a prospective, split lesion
or split face study has probably the maximum impact. If randomized its
probably worth a read!
2. The technology used is as good as its assessment. Subjective percentile
scoring systems and MASI are of little clinical use. An acne scar
improvement of 75% has little meaning unless we qualify the type of scar
improved. Similarly, a MASI improvement of say 40% is of little practical
utility. Also this author is wary of combination studies. Hence, the use of
peels or TC creams with lasers for melasma, has little value as probably
the adjunct has done most of the work !
3. In drug trials a bioequivalence with the comparator is important.
Thus, a laser should be compared with the gold standard therapy.
Thus, cellulite removal is of no use if not compared with surgery;
similarly, melasma should be compared with TC creams and RF with
surgical methods for skin tightening. Even if not formally compared
the reader must sit back and reflect on just what the laser will achieve
over conventional modalities. One important study is histological depth

studies for fractional lasers, which is useful to titrate doses for optimal
depth and are usually the most important studies with the maximum
citations, but rarely asked for while buying the laser !
4. The most important aspect to look for is follow up ! A short-term result
with most nonablative lasers and skin tightening device may not
persist! Conversely, acne scar improvement should be assessed at least
6months after the last session. Melasma studies never look at follow-up
as the lesion recur rapidly. Conversely, even though lentigines and PWS
recur, there is no alternative so laser probably is the only option.
Thus, our choice of studies discussed below reflect the above selection
criterion. Thus, while a large number of excellent studies are published in the
4 leading journals on lasers every year their non-inclusion certainly does not
reflect on the credibility of their data, but the selection criteria that we have
used in the chapter.
LASERS FOR PIGMENTED LESIONS

Are We Near a Perfect Method for Tattoo Removal?
Tatoo removal requires a lot more than a perfectly aligned laser with an
appropriate pulse duration. Even if a laser surgeon has a Qsw Nd:YAG,Qsw
Ruby and Qsw Alex laser, to tackle all types of tattoos, results are often slow and
incomplete.This is as, its often not understood,that the host factor is crucial in
removing the destroyed pigment.But almost no study looks at this factor. Newer
techniques of laser responsive tattoos may help, but with little regulation on
the tattoo artists this is not about to happen in a hurry. Histological assessment
is rarely done and can help in many ways, including locating fibrosis, tissue
depth, granulomatous, and pseudolymphomatousreactions, which can help
rationalize the clinical response.
Besides the QS lasers, which offer a pulse duration already in the
nanosecond range (109 seconds), newer laser technologies have shortened
that pulse time to picoseconds (1012 seconds), promising more effective
results in tattoo removal. Recent published studies already confirm the
effectiveness of shorter pulse lengths in the treatment of tattoos with safety
equivalent to that of Qs lasers (Saedi N). Brauer et al. described the successful
and rapid treatment of 12 tattoos containing blue and/or green pigment with
the novel, picosecond, 755 nm alexandrite laser in men. The research group
demonstrated at least 75% clearance of blue and green pigment after 1 or
2 treatments,with more than two-thirds of these tattoos approaching 100%
clearance. Though a novel rediscovery it would entail a complete overhaul
of the tools and incur a cost in procuring this tool for each coloured tattoo!
Unless of course some company invents a picoseconds probe to attach on to
the existing platforms. In addition to trials on the treatment of tattoos, studies
New Aspects and Controversies in Lasers 473
investigating the picosecond 755 nm alexandrite laser (Cynosure) on facial

scarring and striae using a defractive lens show promising results (Brauer,
2013). Additional studies are underway for its use in melasma. In the future,
additional wavelengths delivering picosecond pulse durations will aid in
more effectively treating red-colored tattoos.
A novel approach could address the issue of emergent removal of tattoos,
as is the case in jobs and recruitment. A method of fine ablation of the
epidermis followed by Qsw Nd:YAG has been found to reduce the sessions
required, with similar results as are achieved with conventional lasers
(Sardana K, 2013). We are now fine tuning the procedure for better cosmesis
using the Er:YAG laser.
Studies have shown that absorption and the strong scattering of epidermal
and dermal tissue significantly reduce the depth of light penetration and
laser energy that may reach the dermal tattoo pigment. This becomes even
more evident when treating red, orange, or yellow pigmented tattoos. These
inks tend to consist of pigments that need shorter wavelength lasers, such
as the 532 nm Qs Nd:YAG, whose effectiveness is limited by skin scattering
and hemoglobin absorption. However, by temporary reduction of the
scattering coefficient of intervening skin layers, increased laser energy and
shorter waveength light may be transmitted more efficiently to the tattoo ink
particles in the skin. Therefore, optical-clearing techniques, with substances
like glycerol, dimethylsulfoxide, and glucose have been shown to significantly
reduce dermal scatter in animal models (Yoon J). A recent study used a glass
microscope slide on the treatment area with a firm pressure to compress
the skin which results in evacuating the blood from the capillary plexus and
found this technique to be useful in tattoo removal (Murphy MJ).
The old idea of the R20R method should not be the standard employed as
after the first impact. The tattoo pigment is shattered and will have an altered
optical property and size which will change the optical absorption. Moreover,
the thermal injury released after even one impact in pigmented skin, can
cause dyspigmentation, due to the photothermal effect of the Q-switched
lasers.
Because tattoo ink fades with each treatment, increasing fluences are
necessary to achieve optimal tattoo removal with each subsequent treatment.
If too high a fluence is used, especially with the initial treatments when the
tattoo is darkest, injury to the skin with scarring can occur. Thus, it is advisable
to increase the diameter of the probe instead of increasing the fluence, which
is usually 4 mm in most devices. A recent study (Bernstein EF) found that with
a novel dynamic system, with the MAX-ON setting the fluence and diameter
were adjusted dynamically so that the size of the spot became progressively
smaller as the fluence is increased with each treatment. For example, the
diameter of the treatment beam using the MAX-ON setting with a fluence of
4.2J/cm2is 6.2 mm, decreasing to 5.2 mm at 6J/cm2, to 4.2 mm at 9.2J/cm2,
and 3.7 mm at 12J/cm2. This achieved superior results as compared to the
conventional probe used.
Nevus of Ota
The most interesting development in this dermal disorder is an understanding
that the condition may have different color hues corresponding to various
size of dermal melanocytosis. Thus, various laser wavelengths may be needed
to treat the disorder effectively. The use of Qsw ND:YAG lasers for all types
of lesions, with their variable response, is easily explained by this new study
which begins to explain why not all lesions respond (Felton et al.). In 20%
of patients, Qs-1,064nm was most efficacious with 97% mean improvement.
The mean improvement was 80% for those in whom Qs755nm was superior,
and 90% for Qs532nm. Number of treatments required varied significantly
according to lesional color and site: gray lesions and those on the forehead/
temple were most resistant.
More such studies can shed light on the appropriate mix and match of
lasers for this difficult problem, instead of using fractional lasers, which has a
marginal effect in dermal pigmentation disorders.
Melasma
Do We Finally Have Laser Treatments That Truly Work?
The ever growing successful therapies for a condition that tends to recur
rapidly, makes it difficult to justify lasers for melasma. In fact the multitude
of therapies is akin to the story of the blind men and the elephant. Each
man is partly right since they have made contact with one major part of
the whole. However, they are all wrong because in their blindness, they
failed to comprehend the creature in its entirety! This aptly describes the
multitudes of therapy for melasma and the devotion of researchers to their
tool! Almost every laser, Er:YAG,Qsw lasers, fractional lasers and the new
addition thullium laser, have been tried for melasma. And the reality is that
unlike the blind men in the aforesaid story, all clinicians know that almost
nothing consistently works except TC creams. Thus, it is best not to attempt to
intervene specially with lasers, as it has been seen that in pigmented skins the
lesion can even worsen, if an improper dose setting is employed.
A recent study examined the 1,927-nm wavelength for melasma in
a Asian population with primarily photodamage skin. (Lee HM). Four
participants (16%) showed greater than 50% improvement, 14 (56%) showed
1150% improvement, and seven (12%) showed 10% or less improvement.
Interestingly, while some of us are enthusiastic about laser toning, other
authors have moved beyond it to more safer tools. In fact, we had in a previous
letter (Sardana K ) pointed out that the Qsw Nd:YAG, laser toning method
can provoke mechanical shockwaves and lead to side effects with both
hyperpigmentation and punctuate leukoderma. A recent study by Chung JY,
et al. looks at a new type of intense pulsed light IPL with pulseinpulse (PIP)
mode (multiple fractionated subpulses in one pulse width). This aims at a
gentler treatment as PIP IPL was designed to overcome the limitation of lowuence IPL. PIP IPL emits the same wavelength as other conventional IPL
devices. Instead of lowering applied uence, it fractionates a pulse duration
of 10 ms into 100 subpulses in which the pulse width of one subpulse is 40s.
Through these fractionated pulses, PIP IPL (E-toning, UnionMedical Co.,
Seoul, Korea) can achieve gentle removal of unwanted pigmentation without
aggravation or are up of melasma. A 54.4% improvement in MASI was seen
on the PIP IPL, which incidentally in Korean skin is good but probably not in
Indian skin types.
Thus, while studies will keep getting published on melasma, two
important issues should always be answered, firstly how does it compare
with conventional therapies and what is the relapse rate. on follow up ? If
a method is able to achieve results better than TC creams on these two
parameters it is definitely worth a look !
Bibliography
1. Brauer JA, Reddy KK, Anolik R, et al. Successfuland rapid treatment of blue and
green tattoo pigment with a novel picosecond laser. Arch Dermatol 2012;148:
820-3.
2. Brauer J, Correa L, Bernstein L, et al. Were not stretching the truth: treatment
of striae with a picosecond 755 nm alexandrite laser and defractive lens array.
Abstract presented at American Society for Laser Medicine and Surgery
Conference. Boston, April 2013;1-6.
3. Bernstein EF, Civiok JM. A continuously variable beam-diameter, high-fluence,
Q-switched Nd:YAG laser for tattoo removal: Comparison of the maximum
beam diameter to a standard 4-mm-diameter treatment beam. Lasers Surg Med.
2013;45(10):621-7.
4. Felton SJ, Al-Niaimi F, Ferguson JE, Madan V. Our perspective of the treatment of
naevus of Ota with 1,064-, 755- and 532-nm wavelength lasers. Lasers Med Sci.
2013;May 4.
5. Hutton Carlsen K, Tolstrup J, Serup J. High-frequency ultrasound imaging of
tattoo reactions with histopathology as a comparative method. Introduction of
preoperative ultrasound diagnostics as a guide to therapeutic intervention. Skin
Res Technol. 2013;Sep 7.
6. Lee HM, Haw S, Kim JK, Chang SE, Lee MW. A split-face study using 1,927
nm Thulium ber fractional laser for photoaging and melasma in Asian skin.
7. Luebberding S, Alexiades-Armenakas M. New tattoo approaches in dermatology.
Dermatol Clin. 2014;32(1):91-6. doi:
8. Marcus L. Treatment of hyperpigmentation-melasma with photodynamic
therapy. J Drugs Dermatol. 2006;5(2 Suppl):9-11.
9. Murphy MJ. A novel, simple and efficacious technique for tattoo removal
resulting in less pain using the Q-switched Nd:YAG laser. Lasers Med Sci. 2014;
Mar 2.
10. Sardana K, Garg VK, Bansal S, Goel K. A promising split-lesion technique
for rapid tattoo removal using a novel sequential approach of a single sitting

of pulsed CO(2) followed by Q-switched Nd: YAG laser (1064 nm). J Cosmet
Dermatol. 2013;12(4):296-305.
Leprol. 2013;79(3):420-2.
12. Saedi N, Metelitsa A, Petrell K, Arndt KA, Dover JS. Treatment of tattoos with a
picosecond alexandrite laser: a prospective trial. Arch Dermatol. 2012;148(12):
1360-3.
13. Yoon J, Son T, Jung B. Quantitative analysis method to evaluate optical clearing
effect of skin using a hyperosmotic chemical agent. Conf Proc IEEE Eng Med Biol
Soc. 2007;2007:33479.
FRACTIONAL LASERS
This is the most talked about technology and we daresay except for some
indications like, ,acne scars, post- traumatic scars, and photodamage, it may
be highly overrated. There are so many issues that have to be understood
before their rampant application, that it is the brave surgeon who ventures to
proclaim where this technology does not work !
Histological Depth
Most FDA approved lasers have to submit in vitro data regarding the depth of
penetration,which is the most crucial aspect specially in treating acne scars.
This is as if the laser MTZ does not reach the depth of the ice pick scar, which
is the deepest of the acne scars, little clinical effect is seen. This is complicated
further by the actual in vivo dynamics of the lasers. This is rarely the topic of
research and is a data that should be elicited from the laser company at the
outset, much before the costing is decided.
As it is not always possible to perform a histology, computer simulation
models have been devised which can have great practical value. Marqa
MF et al. have shown that a computer simulation model used for ablative
FP and non-ablative FP treatment was usually deeper (21 2%) and wider
(12 2%) when compared with histological analysis data. Thus, factoring for
these changes, which is likely due to shrinkage effect of excision of cutaneous
tissues, a good correlation can be established between the simulation and
the histological analysis results. Studies on individual technologies can help
the clinician arrive at a reasonable dose and depth analysis to plan treatment
sessions without having to do an actual histological study.
Aspect Ratio and Depth

The aspect ratio is simple put the volume of the tissue impacted and depends
on the length and width of the laser beam (MTZ). This, in turn, is affected
by various factors, including the,dose, pulse duration, density, temperature,
skin hydration and extensibility. It is surprising how laser surgeons use preset
settings, and report subjective (VAS based) scoring improvements, which in

some cases mask the actual results. For many indications, data on aspect
ratios should be elicited to make the laser intervention meaningful. This
again is readily available from most FDA approved laser manufactures.
Acne Scars
The use of numerous combinations and techniques have rarely focussed on
two prerequisites for results.The first is an objective assessment of scar depth.
This requires a 3 dimensional tool which can put the results into a realistic
perspective.Secondly, there is a need to focus on which type of scar responds
to fractional lasers. This is important as the deep ice pick scars rarely respond
to most lasers. That brings us to another question, that is do all scars ever
respond? Probably not, thus giving an assurance of complete response to a
patient is inadvisable as scars have a memory which is not amenable to
change by the most fractional laser.
Our work(Sardana K ,2014) showed that the deeper icepickice pick scars
do not respond to the fractional Er:Glass even though we changed the aspect
ratio of the laser. Thus, probably it is time to evaluate scar improvement
studies by looking for subscar type improvement than a global assessment
as ultimately with most lasers the deeper scars remain !
Fractional RF is a tool that has been occasionally been used in acne
scars. A recent study by Dr Trelles used the Legato, a new bimodal system
that combines two technologiesfractional ablative unipolar microplasma
radiofrequency (RF) and acoustic pressure ultrasound (US)to deliver
drugs and bioactive compounds into the dermis.The Pixel RF generates
microchannels and provoke thermal damage and fractional ablation. Each
microchannel is on a average 80120 m in diameter and has a depth of
100150 m, depending on the RF power settings. After topical application of
a special compounded preparation into the microchannels, the ultrasound
generated by the ImpactTM module facilitates penetration into the dermis. The
mode of operation is based on mechanical (acoustic) pressure and torques
by propagation of the US wave via the sonotrode to the distal horn and the
creation of a hammering effect. This extracts the liquid from within the
microchannels and forces the bioactive compounds to be enhanced under
the epidermisdermis junction. A rapid improvement was seen in 2 months
in facial acne scarring of about 56.7%, and it seems that radiofrequency,
especially in combination with other methods, can achieve aesthetic results
which are comparable to those achieved with ablative lasers. The study
results depict a marked improvement in icepick scars which is interesting as
the depth of the RF is probably not as deep as the other fractional devices.
A study by Zhang Z et al. looks at microplasma RF where an array of
closely applied microperforations in the skin are generated, which was found
to be as effective as fractional CO2 laser.
Is Nonablative Fractional Laser Inferior to Fractional Ablative Lasers ?

Put simply, is fractional CO2 superior to say, Er:Glass. Such a question, totally
ignores the indication and the parameters used. Using acne scars as the
gold standard, there is enough evidence that there is little difference, if the
appropriate parameters are selected. For other indications the differences
are even less.
Dr Manstein,who invented the technology has allured to this in his
manuscript. Turning the tables, so as to speak, Er:Glass which has a less
absorption capacity for water as compared to CO2 can produce more heat
induced collagen remodelling and thus should be superior to fractional CO2!
Thus, it is best to stick to any one technology then to run after the new kid
on the block. The few studies on this topic have found a marginal difference
in the various technologies and probably a more important question is when
to intervene, thus earlier the better (Cho S, Cho SB). Taking the argument
further there is little to choose over Fractional Er:YAG and fractional CO2
lasers as far as atrophic scars are concerned (Manuskiatti W).
A more important question is why with both ablative and non ablative
lasers, being part of all laser companies inventory, are more studies on this
comparison rarely published. In our experience, this is as the results do not
justify the campaigns to promote one technology over the other.
Complications of Fractional Lasers

It has been our experience that the technology is safe with minimal side
effects. When used according to accepted parameters, fractional CO2 laser
resurfacing is a very safe procedure. The laser surgeon must have a thorough
knowledge of the structure and physiology of skin. Early recognition, close
monitoring, and careful wound care will prevent long-term sequelae when
complications do occur. ( See Appendix Post operative care)
In Asians, the main complication is post-inflammatory hyperpigmen
tation (PIH) which is known to be related to the density and energy of the
device used. An important issue is bulk tissue heating and while this has
been frequently mentioned, variables affecting this have not been previously
addressed. The degree of bulk tissue heating depends upon several factors
including the rate of the energy delivered by the device, the rate of skin
cooling and the rate of heat removal by blood flow.
Is Ultrapulse CO2 Better Than Superpulse CO2

This is definitely true for ablative lasers, but there is neither a study nor any
logical reason to believe that the same principles works in fractional laser.
Interestingly conferences abound in discussions on this and with very little
histological data in public domain a fair assessment cannot be made.
Xu XG et al. have looked at this aspect where they compared the UPCO2
mode (DeepFX microscanner handpiece of the fractional ultrapulsed
CO2laser (Ultrapulse Encore; Lumenis Ltd, Santa Clara, CA), and the SPCO2
mode (AcuPulse CO2 laser device with SurgiTouch Automation System;
Lumenis Ltd).
The parameters were set equally: pulse energy 15 mJ, density 5% (196
MTZ/cm2). Although the depths of ablation were slightly higher on the
UPCO2 side (251.6 10.8 lm) than on the SPCO2 side (245.1 16.8 lm), the
difference was not signicant. Neither were the thermal damage depths or
thermal coagulation zone widths. Though this study was done on the back of
the patients which is not the ideal site for acne scars, it goes to prove that the
pulse debate has little substance.
Another study by the same group (Luo YJ) on the face in photodamage
skin also found no difference. Thus on a purely theoretical level, the only
difference may be that SPCO2 produces more collateral thermal effects
because of the longer dwelling time.
Will Nonablative Rejuvenation Replace Ablative Lasers

The word fractional lasers,refers to a fraction or percentage of the skin
affected by a pass of the laser. This fact is enough to decry any dramatic
results, as the results will still not match the efficacy of ablative lasers. Thus,
ablative laser resurfacing still remains the gold standard for treating advanced
and severe photoaging providing excellent results in experienced hands.
Nonablative resurfacing is ideal for patients under the age of 50 years with
minimal facial sagging, and for those who are unwilling to undergo expensive
and demanding ablative procedures. But the use of any tool alone in facial
rejuvenation is useless and an appropriate mix and match with fillers and
botox is needed for any meaningful results.
Novel Wavelenghths
1565 nm
A new NAFL with no disposable tips, with a handpiece that allows realtime cool-scanning in a stamping fashion, was recently approved by the
Food and Drug Administration (FDA) (M22 [ResurFx module]; Lumenis,
Inc, San Jose, CA, USA). This infrared laser energy at 1565 nm has a slightly
lower absorption coefficient for water than that of 1550 nm (9/cm and 8/
cm, respectively), leading to marginally greater dermal penetration. A wide
variety of shapes, densities, and sizes of patterns are offered, ranging from
5to 18 mm. Energy level ranges from 10 to 70 mJ with density ranging from
50 to 500 spots/cm2. Preliminary results of a 2-center trial treating a total of 30
subjects with visible rhytides (Fitzpatrick Wrinkle Score of 36) and/or striae
alba (present for >1 year), who received a single-pass treatment monthly
for 3 consecutive treatments, shows appreciable results and high patient
satisfaction (Jung JY).
1940 nm Nonablative Fractionated Laser

1940 nm is a novel wavelength that has a higher absorption coefficient for
water than other nonablative wavelengths (14101550 nm) and is weaker
than ablative wavelengths. A new fractional 1940 nm laser comprises
thulium rod pumped by a pulsed alexandrite laser. The fractional patterns are
generated by 3 separate hand pieces (2 dot and 1 grid geometries) whereby a
larger beam is broken up into smaller microbeams by a diffractive microlens
system. Its depth of penetration extends approximately 200 m deep. In a
pilot trial of 11 patients with facial photodamage, rhytides were reduced by
15% and pigment improved by 30% (Ross et al.).
Bibliography
1. Chan HH, Manstein D, Yu CS, et al. The prevalence and risk factors of postinflammatory hyperpigmentation after fractional resurfacing in Asians. Laser
Surg Med 2007;39:381-5.
2. Cho S, Jung JY, Shin JU, Lee JH. Non-Ablative 1550nm Erbium-Glass andAblative
10,600nm Carbon Dioxide Fractional Lasers for Various Types of Scars in Asian
People: Evaluation of 100 Patients. Photomed Laser Surg. 2014;32(1):42-6.
3. Cho SB, Lee SJ, Cho S, Oh SH, Chung WS, Kang JM, Kim YK, Kim DH. Non-ablative
1550-nm erbium-glass and ablative 10 600-nm carbon dioxide fractional lasers
for acne scars: a randomized split-face study with blinded response evaluation. J
Eur Acad Dermatol Venereol. 2010;24(8):921-5.
4. Jung JY, Cho SB, Chung HJ, et al. Treatment of periorbital wrinkles with 1550- and
1565-nm Er:glass fractional photothermolysis lasers: a simultaneous split-face
trial. J Eur Acad Dermatol Venereol. 2010;25:811-8.
5. Lipozencic J, Mokos ZB. Will nonablative rejuvenation replace ablative
lasers?Facts and controversies. Clin Dermatol. 2013;31(6):718-24.
6. Luo YJ, Xu XG, Wu Y, Xu TH, Chen JZ, Gao XH, Chen HD, Li YH. Split-face
comparison of ultrapulse-mode and superpulse-mode fractionated carbon
dioxide lasers on photoaged skin. J Drugs Dermatol. 2012;11(11):1310-4.
7. Manuskiatti W, Iamphonrat T, Wanitphakdeedecha R, Eimpunth S. Comparison
of fractional erbium-doped yttrium aluminum garnet and carbon dioxide
lasers in resurfacing of atrophic acne scars in Asians. Dermatol Surg. 2013;39(1
Pt1):111-20.
8. Marqa MF, Mordon S. Laser fractional photothermolysis of the skin: Numerical
simulation of microthermal zones. J Cosmet Laser Ther. 2014;16(2):57-65.
9. Ramsdell WM. Fractional CO2 Laser Resurfacing Complications. Semin Plast
Surg 2012;26:137140
10. Ross EV, Miller L, Mishra V, et al. Clinical evaluation of a non-ablative 1940-nm
fractional laser. Abstract presented at American Society for Laser Medicine and
Surgery Conference. Boston, 2013;46.
11. Sardana K, Manjhi M, Garg VK, Sagar V. Which Type of Atrophic Acne Scar (Icepick, Boxcar, or Rolling) Responds to Nonablative Fractional Laser Therapy?
Dermatol Surg. 2014;40(3):288-300.
12. Trelles MA, Martnez-Carpio PA. Attenuation of acne scars using high power
fractional ablative unipolar radiofrequency and ultrasound for transepidermal

delivery of bioactive compounds through microchannels. Lasers Surg Med.
2014;46(2):152-9.
13. Xu XG, Gao XH, Li YH, Chen HD. Ultrapulse-mode versus superpulsemode fractional carbon dioxide laser on normal back skin. Dermatol Surg.
2013;39(7):1047-55.
14. Zhang Z, Fei Y, Chen X, Lu W, et al. Comparison of a fractional micro-plasma
radio-frequency technology and CO 2 fractional laser for the treatment of atrophic
acne scars: a randomized split-face clinical study. Dermatol Surg 2013;39:559-66.
LASERS FOR SCARS

Traumatic Surgical and Burn Scars: What Have We Learned?
Cutaneous scars can be complex and thus the approach to therapy is often
multimodal. Intralesional corticosteroids have long been a staple in the
treatment of hypertrophic and restrictive scars. Recent reports suggest the
fractional ablative zones may also be used in the immediate postoperative
period to enhancedeliveryof drugs and other substances. Waibel JS showed
that the use of topically applied triamcinolone acetonide suspension in the
immediate postoperative period helps in better scar resolution.
A recent consensus has concluded that ablative fractional resurfacing,
deserves a prominent role in future scar treatment paradigms. But more
crucial is when and how early can an intervention be employed.With very little
data on record, it remains to be seen, how much the technology can fulfill the
needs of the clinician. There is some proof though that the fractional Er:YAG
is inferior as compared to the fractional CO2 in this regard. Importantly,
consensus guidelines may not apply to all scenarios and continents, specially
if other nonlaser interventions have been tried already. Thus, a patient who
has already tried conventional therapy may not benefit much from fractional
lasers.
Striae Distensae
Striae distensae (SD) represent a common disfiguring cutaneous condition
characterized by linear reddish smooth bands of atrophic-appearing skin.
Novel approaches include treatments with various types of lasers with
the flashlamp-pumped pulsed dye laser (PDL; 585 nm) being the most
commonly reported. Though fractional photothermolysis has been tried
one must understand that interventions depend on the stage of the striae.
Early striae rubra may not require any intervention while for the late stages
striae alba lasers may be tried.
Dr Gauglitz GG in a study from Germany compared ablative Erbium:YAG
fractional laser with 585 nm PDL and found the former to be a better tool for
striae.
Fractional lasers have been used as a method of drug delivery. Issa MC

et al. evaluated the efficacy and safety as well as patients satisfaction using
ablative fractional RF with retinoic acid 0.05% cream and an acoustic pressure
wave ultrasound (US) in patients with alba-type SD on the breast and found
it safe and effective.
Bibliography
1. Anderson RR, Donelan MB, Hivnor C, Greeson E, Ross EV, Shumaker PR,
Uebelhoer NS, Waibel JS. Laser Treatment of Traumatic Scars With an Emphasis
on Ablative Fractional Laser Resurfacing: Consensus Report. JAMA Dermatol.
2013 Dec 11. doi: 10.1001/jamadermatol.2013.7761.
treatment for hypertrophic scars: comparison between Er:YAG and CO2 fractional
lasers. J Dermatolog Treat. 2014;25(4):299-303.
3. Gauglitz GG, Reinholz M, Kaudewitz P, Schauber J, Ruzicka T. Treatment ofstriae
distensae using an ablative Erbium: YAG fractional laser versus a 585-nm pulseddye laser. J Cosmet Laser Ther. 2013 Nov 18.
4. Issa MC, de Britto Pereira Kassuga LE, Chevrand NS, do Nascimento Barbosa
L,Luiz RR, Pantaleo L, Vilar EG, Rochael MC. Transepidermal retinoic acid
delivery using ablative fractional radiofrequency associated with acoustic
pressure ultrasound for stretch marks treatment. Lasers Surg Med. 2013;45(2):
81-8.
LASERS FOR HAIR REMOVAL

Studies comparing lasers are company driven, and it is expected that studies
comparing the in motion technology and the conventional diode lasers will
increasingly be published. Though initial studies did not find any advantage
of the in motion technology, a recent study by Koo B et al. has reignited the
debate.
Though high powered diode lasers have traditionally been used they
can have potential side effects, and thus, an attempt is made at lowering the
energy which should result in less pain and fewer potential adverse events,
but this could theoretically affect the efcacy of the therapy. The in motion
low-energy, high-repetition diode laser pulses of Soprano XL in SHR mode
ensures epidermal cooling and aims at raising the temperature of the subdermal layer of the skin progressively to at least to 45C, less than the thermal
destruction temperature of the hair follicle without heating the epidermis
of the skin region. With this technique, the laser handpiece never remains
stationary in one spot, but is always moving in the treatment area, thus the
skin is never subjected to a single diode laser pulse greater than 10 J/cm2.
Since this is below the threshold of burning, the incidence of adverse effects
is lower making it more acceptable.
Bonnie Koo in a prospective, randomized, side-by-side comparison of

either the legs or axillae compared the Soprano XL 810nm diode in super
hair removal (SHR) mode (Alma Lasers, Buffalo Grove, IL) hereafter known
as the in-motion device vs. the LightSheer Duet 810nm diode laser
(Lumenis) hereafter known as the single pass device. Five laser treatments
were performed 68 weeks apart with 1, 6, and 12 months follow-ups for hair
counts. Pain was assessed in a subjective manner by the patients on a 10-point
grading scale. Hair count analysis was performed in a blinded fashion. There
was a 33.5% and 40.7% reduction in hair counts at 6 months for the single
pass and in-motion devices, respectively. The average pain rating for the
single pass treatment was significantly greater than the in-motion treatment
Garden JM, et al. in a recent study have evaluated a home hair removal
device using combined radiofrequency (RF) and intense pulsed light (IPL)
energy for effectiveness and safety with all skin types (IVI). For the first time,
a home hair removal device has been shown to be effective and safe in all skin
types using a lowenergy RFIPL device. This has wide reaching implications
as a 55% reduction was achieved after 7 sessions which is possibly as the dose
used was conservative. Probably tweaking of the dose would lead to better
results. Further advances in this may make laser centers redundant but would
also lead to more side effects!
Bibliography
1. Bonnie Koo, Kaity Ball, Anne-Marie Tremaine and Christopher B. Zachary. A
comparison of two 810 diode lasers for hair removal: Low fluence, multiple pass
versus a high fluence, single pass technique. Lasers in Surgery and Medicine.
2014; Febuary 7.
2. Garden JM, Zelickson B, Gold MH, Friedman D, Kutscher TD, Afsahi V. Home
hair removal in all skin types with a combined radiofrequency and optical energy
source device. Dermatol Surg. 2014;40(2):142-51.
LASERS FOR VASCULAR INDICATIONS

The response of port-wine stains (PWS) to conventional laser treatment in
adults is difficult to predict. An interesting study by Bencini PL assessed the
influence of local or systemic hemodynamic variables on the clearance of
PWS by using flash lamp-pumped pulsed (FLPP) dye laser. Clearance was
achieved in 50.1% of patients after a maximum of 15 treatment sessions.
Reduced response was associated with, increased age, a newly described
type III capillaroscopic pattern, and presence of lesions in dermatome V2.
Also arterial hypertension was also associated with a lower clinical response.
Thus, the authors concluded that age, arterial hypertension, capillaroscopic
pattern, and body location should be considered when planning laser
treatment of PWS.
Fractional lasers have been used as a method for drug delivery. A recent
study by Ma G et al. in nine patients (16 months) where therapy with the
DeepFx mode (25-30mJ/pulse, 5% density, single pulse) at 1 week interval was
followed by application of timololmaleate 0.5% ophthalmicsolutionwhich
was applied under occlusion for 30 minutes four to five times per day
for an average treatment duration of 14.2 weeks. Four patients (44.4%)
demonstrated excellent regression, and four (44.4%) showed good response.
One of the issues regarding this is the tolerance of fractional lasers in children,
which may be a hindrance to the wide spread use of this combination.
Bibliography
1. Bencini PL, Cazzaniga S, Galimberti MG, Zane C, Naldi L. Variables affecting
clinical response to treatment of facial port-wine stains by flash lamp-pumped
pulsed dye laser: the importance of looking beyond the skin. Lasers Med Sci.
2014;Feb 1.
2. Ma G, Wu P, Lin X, Chen H, Hu X, Jin Y, Qiu Y. Fractional Carbon Dioxide LaserAssisted Drug Delivery of Topical Timolol Solution for the Treatment of Deep
Infantile Hemangioma: A Pilot Study. Pediatr Dermatol. 2014 Mar 6. doi:10.1111/
pde.12299
NONSURGICAL SCULPTING
Body-sculpting and fat-removal procedures are becoming increasingly more
popular. Although diet, exercise, and bariatric surgery may be effective in
controlling obesity, cosmetic procedures may still be necessary to remove
localized adiposity in difcult to locations, such as the anks and abdomen.
Liposuction is the most frequently used method for excess local fat removal,
but it is considered to be an invasive surgical procedure with signicant
risks, including pain, infection, prolonged recovery, scarring, hematoma,
deep vein thrombosis/ pulmonary embolism, and anesthesia-related
complications. These risks and associated downtime have led patients
to seek out alternatives, such as noninvasive body contouring. Currently
available noninvasive fat removal methods include low-level laser therapy,
radiofrequency, ultrasound, infrared light, and cryolipolysis
An extensive elucidation of conventional modalities like RF and focused
ultrasound applications is detailed in chapter 10
Cryolipolysis (CoolSculpting, Zeltiq, Pleasanton, CA) is a novel method of
selective removal of fat with cooling. This technique is based on the concept
that fat cells are more sensitive to cold than the surrounding tissue. Prior
studies and observations have demonstrated that cold exposure can induce
selective damage to the subcutaneous fat via induction of panniculitis,
resulting in reduction in the supercial fat layer of the skin. Dr Lilit Garibyan
have published a study where volume changes and quantication after
noninvasive fat removal in comparison to an internal control were done
using 3D photography and reported about 39.6 cc of fat loss of the treated
ank at 2 months after a single treatment cycle.
Cellulite affects 95% of women and is often treated by various means.
Acoustic wave therapy (AWT) using extracorporeal pulse activation
technology (EPAT) can also be used to manage cellulite (Adatto M). The
difference between treated and untreated legs was statistically significant
with regard to depressions, elevations, roughness and elasticity after the first
follow-up visit.Thus, this may be a safe and effective treatment alternative for
the temporary improvement in the appearance of cellulite.
Bibliography
1. Adatto M, Adatto-Neilson R, Servant JJ, Vester J, Novak P, Krotz A. Controlled,
randomized study evaluating the effects of treating cellulite withAWT/EPAT.
JCosmet Laser Ther. 2010;12(4):176-82.
2. Coleman KM1, Coleman WP 3rd, Benchetrit A. Non-invasive, external ultrasonic
lipolysis. Semin Cutan Med Surg. 2009;28(4):263-7.
3. Fatemi A. High-Intensity Focused Ultrasound Effectively Reduces Adipose
Tissue. Semin Cutan Med Surg. 2009;28:257-62.
4. Garibyan L, Sipprell WH 3rd, Jalian HR, Sakamoto FH, Avram M, Anderson RR.
Three-dimensional volumetric quantification of fat loss following cryolipolysis.
Lasers Surg Med. 2014;46(2):75-80.
5. Jewell ML, Baxter RA, Cox SE, Donofrio LM, Dover JS, Glogau RG, Kane MA,
Weiss RA, Martin P, Schlessinger J. Randomized sham-controlled trial to evaluate
the safety and effectiveness of a high-intensity focused ultrasound device for
noninvasive body sculpting. Plast Reconstr Surg. 2011;128(1):253-62.
6. Sadick N. Thermage Radiofrequency for Noninvasive and Nonablative Body
Contouring Cosmetic Dermatology, 2010;23(12):555-560
7. Sasaki GH, Tevez A. Clinical efficacy and safety of focused-image ultrasonography:
A 2-year experience. Aesthet Surg J. 2012;32:601-12.
8. Sasaki GH, Tevez A. Microfocused Ultrasound for Nonablative Skin and
Subdermal Tightening to the Periorbitum and Body Sites: Preliminary Report
on Eighty-Two Patients. Journal of Cosmetics, Dermatological Sciences and
Applications. 2012;2:108-16.
Microfocused Ultrasound With Visualization

Acne
Although the mechanism of action remains unclear, it is hypothesized that
with the use of 1.5 mm and 1 mm depth probes, focal thermal coagulation
points are delivered into sebaceous glands, rendering them in active. In a pilot
study in which 10 subjects received 3 treatments, 14 days apart with MFU-V,
a significant decrease in sebum, as measured by a sebumeter (CourageKhazaka, Cologne, Germany), was noted over the forehead, cheeks, and
chin 60 days after treatment. Eighty percent of the subjects had a decrease in
total acne lesion count at 60 days, and 100% of subjects showed a decrease at
180days after the last treatment.
Probably the future may hold a promise for treating moderate-to-severe

inflammatory acne.
Bibliography
1. Munavalli G. Single-center, prospective study on the efficacy and safety of
microfocused ultrasound with visualization for the noninvasive treatment of
moderate-to-severe facial acne. Abstract presented at American Society for Laser
Medicine and Surgery Conference. Boston, April. 2013:4-6.
NOVEL WAVELENGTHS
Sebaceous Glands
Sakamoto et al. have looked at wavelengths that target sebaceous glands and
narrowed down the search to 1210, 1728, 1760, 2306 and 2346 nm. Laserinduced heating at 1710 and 1720 nm was about 1.5-fold higher in human
sebaceous glands than in water. With the use of wavelengths that more
specifically target sebum, the investigators hypothesized that SP of sebaceous
glands, another part of hair follicles, may equate to the success of permanent
hair removal.
In a pilot clinical study to evaluate the efficacy of a novel 1720 nm laser
in the treatment of sebaceous hyperplasia, 4 patients underwent a test spot,
followed by 2 full treatment sessions using the 1720 nm laser (Del Mar Medical
Technologies, Del Mar, CA, USA). A 400 mm fiber, with a mean fluence of
45 J/cm2, spot size of 750 mm, and pulse duration of 50 milliseconds was
used. The desired end point was a change from pretreatment granular yellow
appearance to a creamy-white smooth surface. Many of the lesions resolved
almost completely after a single treatment, and no additional treatment was
required.
Thus, the future may hold a hope for treatment of sebaceous hyperplasia,
ectopic sebaceous glands, acne vulgaris, and laser hair removal, with this
wave length.
Wavelength 1210 nm
Absorption peaks near 915, 1210, 1400, 1720, and 2346 nm have been
demonstrated for lipids. A study to evaluate the histologic changes over
time of a novel noninvasive treatment with a 1210 nm laser with surface
cooling, to more selectively target fat, was performed on 8 patients before
abdominoplasty. The investigators concluded that significant zones of
fat reduction in hypodermal necrosis could be achieved, while including
or avoiding damage to the lower dermis depending on the settings used.
Clearance of the damaged adipocytes proved slow, with residual damage still
present at 6 months (Echague AV).
A clinical trial was performed to evaluate the use of the 1210-nm
wavelength (ORlight, Potters Bar, UK) for fat preservation (Centurion P
et al). This was a concept known as selective potothermostimulation (PSP), a

concept whereby the wavelength has the ability to stimulate adipocytes and
mesenchymal cells of the subcutaneous tissue. One hundred two patients
were treated with the 1210-nm diode laser and followed. Histologic analyses
revealed a 98% preservation of aspirated adipocytes. The investigators
hypothesize that this selective PSP and preservation of the integrity of
adipocytes makes this laser wavelength ideal when performing laser-assisted
liposculpture followed by fat grafting or breast reconstruction.
There may be a potential use of this laser for laser-assisted lipoplasty and,
perhaps, the removal of large lipomas.
Bibliography
1. Centurion P, Noriega A. Fat preserving by laser 1210-nm. J Cosmet Laser Ther.
2013;15(1):2-12.
2. Echague AV, Casas G, Rivera FP, et al. Over time histological tissue changes after
non-invasive treatment with a 1210 nm laser. Abstract presented at American
Society for Laser Medicine and Surgery Conference. Boston, April 2013;4-6.
3. Sakamoto FH, Doukas AG, Farinelli WA, et al. Selective photothermolysis to
target sebaceous glands: Theoretical estimation of parameters and preliminary
results using a free electron laser. Lasers Surg Med. 2012;44(2):175-83.
4. Winstanley D, Blalock T, Houghton N, et al. Treatment of sebaceous hyperplasia
with a novel 1,720 nm laser. J Drugs Dermatol. 2012;11(11):1323-6.
Laser Treatment for Axillary Hyperhidrosis

There are few isolated retrospective and case studies reporting the use
of Nd:YAG lasers subdermally in the treatment of hyperhidrosis. Most
recently, Yanes presented results on the use of the 924/927 nm diode laser
subdermally,via a 1.5-mm diameter flexible fiber, to selectively destroy
axillary sweat glands before aspiration and curettage. Although microwaves
are not commonly used in cutaneous surgery, they are able to focus heat at
the interface between the skin and subcutaneous tissue, causing irreversible
thermal necrosis of both apocrine and eccrine glands. In 2011 a microwave
device was approved by the FDA for the treatment of primary axillary
hyperhidrosis (Johnson et al.).
MFU-V has been investigated for the treatment of axillary hyperhidrosis.
In a randomized, double-blind controlled trial, 12 of 20 hyperhidrotic adults
with Hyperhidrosis Disease Severity Scale scores of 3 or 4 underwent 2
treatments, 30 days apart. The sham group (8 of 20) received treatment with
the energy turned to 0 J. Patients were followed for 4 months, and a response
rate of 67% to 83% ( P < 0.005) was seen across all post-treatment time points
for the active group, versus 0% for the sham group (Nestor M).
The use of a novel microwave energy device that destroys eccrine glands
at the interface of the deep dermis and subcutis, minimizing damage to
surrounding tissue has been used for axillary hyperhidrosis (Hong HC).
An earlier-generation device was reported to be efficacious and safe in a
randomized, blinded, multicenter study. Glaser DA in a RCT studied a similar
device and found that thirty days after treatment, the active group had a
responder rate of 89% (72/81), and the sham group had a responder rate of
54% (21/39) (P < 001). Treatment efficacy was stable from 3 months (74%)
to 12 months (69%), when follow-up ended. Adverse events were generally
mild, and all but one resolved over time. This US FDA approved device may
provide a simple treatment for this distressing disorder
Bibliography
1. Glaser DA, Coleman WP 3rd, Fan LK, et al. A randomized, blinded clinical
evaluation of a novel microwave device for treating axillary hyperhidrosis:
the dermatologic reduction in underarm perspiration study. Dermatol Surg.
2012;38(2):185-91.
2. Jacob C. Treatment of hyperhidrosis with microwave technology. Semin Cutan
Med Surg. 2013;32(1):2-8.
3. Johnson JE, OShaughnessy KF, Kim S. Microwave thermolysis of sweat glands.
Lasers Surg Med. 2012;44(1):20-5.
4. Johnson JE, OShaughnessy KF, Kim S. Microwave thermolysis of sweat glands.
Lasers Surg Med. 2012;44(1):20-5.
5. Nestor M, Hyunhee P. Randomized, double-blind, controlled pilot study of the
efficacy and safety of micro-focused ultrasound for the treatment of axillary
hyperhidrosis. Abstract presented at American Society for Laser Medicine and
Surgery.
6. Yanes FD. G: laser-assisted minimally invasive surgery for primary hyperhidrosis.
Abstract presented at American Society for Laser Medicine and Surgery
Conference. Boston, April 2013; 4-6.
HOME USE DEVICES

Over the past several years, several home-based cosmetic devices have been
introduced in the market. These miniaturized devices are designed to address
a variety of indications, including photorejuvenation, acne, hair growth, and
hair removal. They are underpowered yet have specific safety features to
ensure that nonprofessional operators can use them with ease.
Fractional Devices
One of the first fractional, photorejuvenation devices to be launched was the
PaloVia Skin renewing Laser (Palomar Medical Technologies, Burlington,
MA, USA). This hand-held, nonablative diode laser (1410 nm, 15 mJ,
10 millisecond pulse duration) has been cleared by the FDA for reduction
of fine lines and wrinkles around the eyes. Another home-based, fractional
diode device (1435 nm, 1.2 W) is the Philips Reaura (Philips, Amsterdam, the
Netherlands), with initial studies claiming rejuvenation effects in 8 weeks

following twice-weekly application. In addition, new in-home radiofrequency
devices have been developed and are presently being investigated for their
effects on photorejuvenation. More recently, a prototype in-home NAFL
device for the treatment of solar lentigines has been developed (Laserscript;
Palomar Medical). This 1410 nm, nonablative diode was used to treat
33patients in a pilot trial in which subjects treated themselves with energies
up to 30 mJ per microbeam for 4 weeks, and were followed for 3 months
(Weiss R).
Hair Growth Devices

Home-based hair growth devices, such as the HairMax LaserComb
(LexingtonInternational, LLC, Boca Raton, FL, USA), Laser Cap (Transdermal
Cap, Inc, Gates Mills, OH, USA), and TOPHAT655 device (Apira Science, Inc,
Newport,CA, USA) incorporate a low-level light therapy concept also found in
their in-office counterparts. These hair-growth devices contain low-powered
laser diodes with wavelengths in the region of 630670 nm, and are thought
to induce proliferative activity in hair follicles resulting in terminalisation of
vellus human hair follicles. In a double-blind, randomized controlled trial
of 41 males, the laser group received 25-minute treatments in a bicyclehelmetlike apparatus (TOPHAT655) every other day for 16 weeks. When hair
counts at 16 weeks were compared with baseline counts, a 39% increase in
hair was demonstrated in the laser treated group (Lanzafame R).
Hair Removal Devices

Several home-based hair-removal devices are available that attempt to
replicate office devices, including the Tria Laser using a diode 810 nm laser
(Tria Beauty, Inc, Dublin, CA, USA) and the Silkn (Home Skinovations,
Yokneam, Israel) that was developed according to the concept of IPL
technology.
Acne Therapy
Several home-based acne devices are also currently available. These devices
use blue and red light diodes, heat, and IPL to treat mild to moderate acne,
especially among patients who are hesitant to consider or have already failed
other therapeutic options.
Bibliography
1. Weiss R, Doherty S. Clinical study of physician directed home-use non-ablative
fractional device for the treatment of pigmented lesions. Abstract presented at
American Society for Laser Medicine and Surgery Conference. Boston. April
2013;4-6.
TRASER
Total reection amplication of spontaneous emission of radiation (TRASER)
device, is a dye-based device, which uses three highly uorescent TRASER
dyes, PM 556 (pyrromethene 556), Rh 590 (rhodamine 590), and SRh 640
(sulforhodamine 640 chloride) (Exciton, Inc., Dayton, Ohio). This device
amplifies spontaneous emission of radiation by capturing and retaining
photons through total internal reflection; hence, the acronym. TRASER is
associated with minimal dye degradation, as the dye is not stressed with
typical laser gain pump levels, making the lifetime of the dye over 70,000
pulses. The characteristic carbon lter dye exchange depots used in current
pulsed dye lasers (PDL) for the rhodamine dyes are not required in a TRASER
as saturation of the dye-solution is not necessary or desired. Comparison
of the currently congured TRASER with a PDL indicates that a TRASER is
capable of providing several times the amount of energy when delivered
over, for instance, 4 milliseconds at 12 mm. The workhorse PDL pulse train
is limited to a 0.45 millisecond pulse before pulse degradation occurs. No
such degradation occurs in a TRASER pulse because there is no population
inversion required for the light amplication and no triplet state quenching
of the pulse occurs, negating the need for cyclooctatetetraene (COT) or other
additives to the dye solution.
The ability to make variations in pulse durations may be useful and could
affect treatment outcomes. For example, if an optimal pulse comprises a series
of 0.45 millisecond pulses, then this could be reproduced with a TRASER. If
on the other hand it is determined that a continuous at 10100 milliseconds
pulse is desirable, then this too could be provided.
Morgan Gustavsson, in their work showed a TRASER with appropriate
wavelengths and pulse durations has more than enough energy to deliver
clinically predictable effects.
Applications
1. One example of a prime target for a Traser would be hair removal. Studies
indicate that high peak powers can be obtained at these wavelengths
even over long 10100 msec pulses, and as such this wavelength may
well be considered more favorably in the future for hair removal. Clearly
darker skin types would require reduced fluence, efficient cooling and
longer pulse duration, but Asians and Caucasians in particular could
benefit from the significant melanin/hemoglobin absorption differential
with this wavelength.
2. Given the design of a Traser, it is generally more ecofriendly and safer
than corresponding dye lasers. The current dye lasers use flammable
and toxic organic solvents with additives, such as the cyclooctatetraene
(COT). By comparison, the Trasers are operated using water as the host
(i.e. the solvent) for the Traser dye, and do not require toxic solvent
additives. Furthermore, the closed system in a Traser avoids any dye
or solvent contact with the operator. A Traser can be operated with a
peak at any of the common yellow dye lasers without the use of any
toxic solvents, solvent additives, or toxic dyes. Even with the use of
rhodamines, with water as a solvent and without any additives, the
Traser is ecofriendlier than the corresponding lasers.
3. Traser emission spectra match hemoglobins absorption wavelengths,
indicating that a Traser could be used to treat the same vascular
conditions as the PDLs by the same selective photothermolysis
mechanisms. For superficial port wine stains, the shorter wavelengths
with shorter pulse durations may be optimal, and for those with thicker,
more nodular problems, the longer wavelengths with longer pulses
might be preferred. Further, one can predict good responses in patients
with lentigenes and in hair removal.
4. Given that a pulsed dye Traser is tunable, is should be able to mimic
devices from below the 532 nm (green) to the near infrared wavelength
simply by changing the dye kit. The durability of the flashlamps in a
Traser are likely to be significant, given the relatively low peak powers
and longer individual pulse durations (0.45 msec) and the consequent
wear and tend on both the lamps.
5. Trasers should compare well with an intense pulse lights (IPL). Trasers
have chromophor-absorption selective spectra that are quite similar to
those of lasers. Since there is less interference by wavelengths induced by
less selective absorption, the fluences required to induce the same peak
power output is reduced. Even with short pulses, Trasers are capable
of producing high peak powers within a narrow wavelength spectrum,
a feature impossible in the case of IPLs. The fluences delivered from a
Traser are in parity with, or exceed, those delivered by a comparable
laser, even at short pulse-durations. This is even more evident when
compared to an IPL.
Thus TRASER is well on its way to become the next IPL in coming years.
In fact it might be PDL cum IPL, though whether the clinical results reflect its
design and dynamics is yet to be seen.
Bibliography
1. Gustavsson M, Spanogle JP, Berganza L, Zachary CB. TRASER: Dye Cell Aspect
Ratio and Parallel vs. Sequential Pulsing and their Relation to Energy Output.
Lasers in Surgery and Medicine (2014)46:140-3.
2. Zachary CB, Gustavsson M. TRASERTotal reection amplication of
spontaneous emission of radiation. PLoS ONE 2012;7(4):e35899.
Conclusion
There are many complex issues that arise out of lasers and their applications.
As most publications are from experts, who to their credit, disclose affiliations
with the laser and device manufacturers, its only when the results are
replicated does the technology find universal acceptance. It is impossible to
preempt such research as, it is essential to possess the identical technology
and then report objective results. The first requires an endless source of
funding and the latter time and expertise to publish, the combination of
which is rarely see outside the countries of their invention. Thus, it is better
to wait for studies from across the world specifically in skin types IV and V
before investing in any new device.
But as lasers and now TRASERS have multiple indications and involve
big companies and investors, novel technology and applications will keep
occurring and it is indeed a onerous task for the clinician to sift and decide
what technology to invest. Whether home use devices will become common
place remains to be seen but trends show that as clinicians become aware
of the technological limitations the consumer may be directly targeted by
companies. The future may see drug delivery via fractional lasers, and thus,
this is a field that will remain alive for many years to come!
Acknowledgements
We thank Dr Inder Raj S. Makin for his critical comments and suggestions
to make the chapter relevant and topical. The lack of undue emphasis on
Microfocused Ultrasound With Visualization in this chapter is as, an excellent
contribution on the same has already been included in the book (Chapter 9).
APPENDIX
Laser Safety/Eye Care
CLASSIFICATION OF LASERS*
Lasers are categorized into four hazard classes based on the accessible
emission limits (AELs). These limits are listed in EN 60825-1 and the American
National Standards ANSI Z136.1 for Safe Use of Lasers.
The AEL values for the laser classes are derived from the medical MPE
(maximum permissible exposure) values. The MPE values specify the danger
level for the eye or the skin with respect to laser radiation. Since November
2001, the laser classes are as listed in Table A1.1.
This classification (Table A1.1) has resulted in the introduction of three
new laser classifications 1M, 2M and 3R and the abolition of Class 3A.
The letter M in Class 1M and Class 2M is derived from magnifying:
optical viewing instruments.
The letter R in Class 3R, is derived from reduced or relaxed
requirements. The R requirement relates to certain equipment and user
specifics, e.g. Manufacturerno key switch and interlock connector required;
Userno eye protection is usually required.
The Letter B in Class 3B is historical.
It should be noted that in the previous laser classification scheme, lasers
were grouped into four main classes and two sub-classes (i.e. 1, 2, 3A, 3B and
4); these classifications will still apply to older lasers that are currently in use.
The pulsed lamp criteria, including IPL, apply to a single pulse and to any
group of pulses within 0.25 seconds. The hazard values are at a distance of 200
mm. The risk group determination of the lamp being tested is detailed in the
standard.
WARNING SIGNS AND LABELS

The nominal hazard zone (NHZ) is the physical space in which levels of
radiation, direct, reflected, or scattered, exceed the maximum permissible
exposure (MPE), which may be determined by the safety information
* Laser Classes to EN 60825-1 (Nov. 2001) and Safety

Table A1.1 Classification of lasers
Labels
Description
Comment
The radiation emitted by this laser is not

dangerous
No need for protection

equipment
1M
Eye safe when used without optical instruments,

may not be safe when optical instruments are
used

equipment, if used without
optical instruments (e.g.
focusing lenses)
Eye safe due to aversion responses, including

the blink reflex

equipment
2M
The light that can hit the eye has the values
of a class 2 laser, depending on a divergent or
widened beam; it may not be safe when optical
instruments are used

equipment, if used without
optical instruments
3R
The radiation from this laser exceeds the

maximum permissible exposure (MPE)
values. The radiation is maximum 5 times the
acceptable emission limits (AEL) of class 1
(invisible) or 5 times the AEL of class 2 (visible)
The risk is slightly lower than that of class 3B
Dangerous to the eyes, safety

glasses are recommended
3B
Old class 3B without 3R. Directly viewing the

laser beam is dangerous. Diffuse reflections are
not considered as dangerous
Dangerous to the eyes, safety

glasses are obligatory
Old class 4 Even scattered radiation can be

dangerous, also danger of fire and danger to the
skin
Personal safety equipment is

necessary (glasses, screens)
provided by the manufacturer. While a Class III or Class IV laser is in operation,

appropriate warning signs and labels, as well as protective equipment is
administratively required for all individuals within the NHZ. Warning signs
and labels are provided by the ANSI Z 136.3 in accordance with the Federal
Laser Product Performance Standard, including the following two:
1. Display of Warning Signs

Warning signs shall be conspicuously displayed on all doors entering the
laser treatment controlled area (LTCA), so as to warn those entering the area
of laser use. Warning signs should be covered or removed when the laser is
not in use (see Atlas).
2. Inclusion of Pertinent Information

Signs and Labels shall conform to the following specifications. (Figs A1.1 and
A1.2)
A. The appropriate signal word (Caution or Danger) shall be located in the
upper panel.
Laser Safety/Eye Care 495
There are different logotype labeling requirements for Class IIIA lasers
with a beam irradiance that does not exceed 2.5 mW/cm2 (Caution
logotype) and those where the beam irradiance does exceed 2.5 mW/
cm2(Danger logotype).
Class II or Class III areas: All signs (and labels) associated with these
lasers (when beam irradiance for Class III does not exceed 2.5 mW/cm2)
use the ANSI CAUTION format: yellow background, black symbol and
letters (Fig A1.1).
Class III (beam irradiance 2.5 mW/cm2), Class III and Class IV lasers:
Require the ANSI DANGER sign formatwhite background, red laser
symbol with black outline and black lettering (Fig. A1.2).
B. Adequate space shall be left on all signs and labels to allow the inclusion
of pertinent information. Such information may be included during the
printing of the sign or label or may be handwritten in a legible manner,
and shall include the following.

i. At position 1 above the tail of the sunburst, special precautionary
instructions or protection action such as Laser Surgery in Process
Eye Protection Required.

a. For Class II lasers and laser systems, Laser Radiation: Do Not
Stare into Beam.

b. For Class III lasers and laser systems where the accessible
irradiance does not exceed the appropriate MPE based on a
0.25s exposure, Laser Radiation: Do Not Stare into Beam or
View with Optical Instruments.
Fig. A1.1: Laser caution sign: CAUTION (Class II and some Class IIIR lasers). This
label will also have the type of laser designated (HeNe, Argon, CO2, etc.) and the power
or energy output specified
Fig. A1.2 : Laser caution signs :DANGER (some Class III R, all Class III B and
Class IV lasers)
c. For all other Class IIIR lasers and laser systems, Laser
Radiation: Avoid Direct Exposure to Beam.
d. For all Class IIIB lasers and laser systems, Laser Radiation:
Avoid Direct Exposure to Beam.
e. For Class IV laser and laser systems, Laser Radiation: Avoid
Eye or Skin Exposure to Direct or Scattered Radiation.
ii. At position 1 above the tail of the sunburst, special precautionary
instructions or protective action such as: Laser Surgery in Process:
Eye Protection Required.
iii. At position 2 below the tail of the sunburst, type of laser (Nd:YAG,
CO2, etc.) or the emitted wavelength, pulse duration (if appropriate),
and maximum output.
iv. At position 3, the class of the laser or laser system.
Eye Safety
Usually, the eyes protect themselves from damage that could be induced
by excess radiation energy. If the retina detects high radiation intensity, the
eyelid is closed in an automatic reaction. However, the time span that is
necessary to close the eyelid is about 250 ms, which is definitely longer than
most of the pulse durations used for lasers. In addition, this safety feature
reliably works for an optical power of less than 1 mW, which is quite small
compared to lasers or ILSs. Thus, the eye blink is not sufficient protection
except against some nonmedical lasers classified in group 1.
Radiation that is invisible for the eyes (ultraviolet, infrared) will not
trigger an eye blink to protect the cornea, lens, or retina from damage. Users of
lasers or ILSs should always keep in mind that even small intensities reaching
the open pupil can cause severe damage of the retina, which in most cases
is irreversible and may entail a complete loss of eye sight. Besides the eyes,
radiation from lasers or ILSs can also damage skin outside the treatment area.
One of the most important safety issues is the protection of the eyes from
radiation that exceeds the maximum permissible exposure (MPE) values for
the eyes. Essential parts of the eye such as the cornea, the lens, the choroid, and
the retina can be subjected to radiation-induced damage. The part of the eye
that sustains damage depends on the wavelength of radiation. The unwanted
effects of radiation in the eye are more or less comparable to those effects
at the treatment site. Depending on the intensity at the site of interaction,
the well-known effects of coagulation (low intensity), vaporization (high
intensity), and ablation (very high intensity) may occur.
In the spectral range of light of about 3701,000 nm, radiation readily
penetrates the cornea and the lens to reach the choroid and retina. The
radiation of this spectral range is, for example, well absorbed in hemoglobin
in choroid vessels The induced heat simultaneously damages the retina.
Additionally, when visible radiation passes the lens and cornea, the
refraction increases the intensity of the incoming radiation by several orders
of magnitude.
The wavelengths from about 7501,000 nm are particularly dangerous to
the retina. Radiation in this spectral range is invisible and will not be detected
by the eye and, therefore, the eye will not blink.
The risk of damage to the eye depends on various factors including the
wavelength, pulse duration, pupil size and amount of pigmentation of the
pupil (Fig. A1.3 and Table A1.2).
1. UV-light below 350 nm either penetrates to the lens or is absorbed at
the surface of the eye. A consequence of exposure to high power light at
these wavelengths is an injury to the cornea by ablation or a cataract.
2. Light in the visible wavelength region (380780 nm) penetrates to the
retina. The eye is sensitive to radiation and humans have developed
natural protective mechanisms. When light appears too bright, which
means that the power density exceeds the damage threshold of the eye,
we automatically turn away and close our eyes. This is known as an
aversion response or blink reflex. This automatic reaction is effective for
radiation up to 1mW power. With higher power levels, too much energy
reaches the eye before the blink reflex can respond, which can result in
irreversible damage.
3. The near infrared wavelengths (7801400 nm) are a type of radiation
that is particularly dangerous to the human eye because there is no
natural protection against it. The radiation again penetrates to the retina,
but the exposure is only noticed after the damage is done.
4. Infrared radiation (140011000 nm) is absorbed at the surface of the
eye. This leads to overheating of the tissue and burning, or ablation, of
the cornea.

Table A1.2 Effect of light on the skin and eye
Wavelength
Eye effects
Skin effects
Ultraviolet C (0.2000.280m)
Photokeratitis
Erythema (sunburn)
Skin cancer
Ultraviolet B (0.280315m)
Photokeratitis
Accelerated skin aging

Increased pigmentation
Ultraviolet A (0.3150.400m)
Photochemical UV
cataract
Pigment darkening
Skin burn
Visible (0.4000.780m)
Photochemical and
thermal retinal injury
Photosensitive reactions
Skin burn
Infrared A (0.7801.400m)
Cataract, retinal burns
Skin burn
Infrared B (1.4003.00m)
Corneal burn
Aqueous flare
IR cataract
Skin burn
Infrared C (3.001000m)
Corneal burn only
Skin burn
Fig. A1.3: Spectrum of light and its penetration into the eye
IMPLEMENTATION OF LASER SAFETY

Eye Safety Standards
Because physicians have to view the patient and the treatment area, the
optical filters must fulfill both criteria at the same time: protection against
laser or intense light sources (ILS) radiation and sufficient transmission
of daylight to enable viewing. To achieve maximal safety for the eyes, it is
important to adjust the optical filters of the safety goggles to the radiation
source used (laser or ILS). The important parameters of the radiation sources
are wavelength, pulse duration, intensity, and radiant exposure. These

parameters of a laser or ILS system determine the characteristics of the safety
goggles. Each laser or ILS requires special safety goggles that are labeled for
their use (wavelength range of protection, laser mode, and scale number
of protection). If a physician uses several lasers or ILSs, confusion of safety
goggles of the different systems is possible and must absolutely be avoided.
Laser Safety Standards

The MPE, maximum permissible exposure is a measure of the radiation
exposure one can have without hazardous effect. This actually determines
the OD and the NHZ.
The American standard for laser safety eyewear only requires specification
according to the optical density (OD) of the filters. The Optical Density (OD
or D (l)) is the attenuation of light that passes through an optical filter. The
higher the OD value, the higher the attenuation. The American standard also
allows a Nominal Hazard Zone (NHZ) to be determined by the laser safety
officer (LSO). Outside of the NHZ, diffuse viewing eyewear is allowed.
However, in Europe there is a second criteria which must be taken into
consideration - the power or energy density (i.e. the power or energy per
area = per beam area). The Diffuse viewing condition is not allowed and
laser safety glasses must protect against a direct laser exposure. Protection
due to Optical Density alone is not sufficient when the material itself cannot
withstand a direct hit. The European regulations are legal requirements and
enforceable. Other legal requirements (e.g. the regulations for industrial
safety as well as the medical equipment regulations) also refer to these.
Laser safety eyewear ratings take both the eyewear filters and the eyewear
frames into account to provide a specific rating for each different combination
of wavelength, power and temporal mode of the laser. This differs from the
optical density value. It is an absolute measure of the maximum power
of the beam that the eyewear can withstand, without degradation to the
performance of the eyewear.
The European laser safety standards EN 207/EN208 also require that the
frame also has to withstand the same level of radiation as the filters. The
laser beam must be prevented from reaching the eyes from the sides and
the filters should form an inseparable unit with the frame. The weaker
part determines the protection level of the whole system for the specified
wavelength and operation mode.
Understanding the Laser Safety Eyewear Rating

Lasers differ from each other not only in wavelength or optical power, but also
in the way in which the power is emitted. Power can be emitted continuously
(continuous wave operationCw) or in form of pulses (long pulse, giant
pulse/q-switched or mode-locked) (Table A1.3).

Table A1.3 Summary of laser operation modes/pulse duration
Operation
mode
Description
Typical pulse length
Marking
on eyewear
Continuous
wave (Cw)
The continuous emission of

laser radiation
< 0.2 s
Pulse mode
The short-term single or

periodically repeated emission
of laser radiation
> 1 s to 0.25 s
Giant pulse
mode
(Q-switch)
It is like pulsed mode, but the

pulse length is very short
1 s to 1 ns
Mode locked
It is the emission of laser

radiation with all the energy
stored in the laser medium
released within the shortest
possible time
< 1 ns
In case of pulsed operation with a low pulse repetition rate, the peak
power of each single pulse is the critical value. If the repetition rate increases,
the average power needs to be taken into consideration. Please note that
some lasers can be operated in different modes.
Laser safety eyewear is specified according to these operation modes.
Protective eyewear for repetitively pulsed lasers must satisfy the D rating as
well as the I, R or M rating appropriate to its pulse length.
The LB number is the scale defined in the Standard EN 207:2009. This
specifies eyewear protection against laser radiation using a glass or plastic
material. The LB rating calculation defines the minimum markings required
on the laser safety glasses to ensure protection from the specified laser, at the
target distance selected.
The letters in front of the LB number refer to the temporal mode of the
laser beam as seen above.
Drefers to Cw lasers or average Power Density (exposure time > 0.25s).
Irefers to lasers with pulse lengths between 1 ms and 0.25s.
Rrefers to lasers with pulse lengths between 1ns and 1ms.
Mrefers to lasers with pulse lengths less than 1ns.
Protective eyewear for repetitively pulsed lasers must satisfy the D rating
as well as the I, R or M rating appropriate to its pulse length. The second
part defines the wavelength, or range of wavelengths, at which the rating is
valid. The final part of the CE rating is the LB rating itself. This integer value
represents the maximum power that the eyewear filters protect against.
For example:
D 532 LB3: This eyewear delivers LB3 protection for a D type beam
(continuous wave) at 532 nm.
DIR 1000-1300 LB5:This eyewear delivers LB5 protection for D,I and R type
beams across the wavelength range 10001300 nm.
BIBLIOGRAPHY
1. ANSI/IESNA RP-27.2-2000. Recommended Practice for Photobiological Safety
for Lamps and Lamp Systems - Measurement Techniques.
for Lamps and Lamp Systems - General Requirements.
for Lamps - Risk Group Classification and Labeling.
4. Guidance on the safe use of lasers in education and research. Association of
university radiation protection officers. Aurpo guidance note no. 7.2012, Revised
edition.
5. IEC 60825-1 (2nd edition-2007). Safety of laser products - Part 1: Equipment
classification, and requirements.
6. IEC 60825-1 (2nd edition - 2007). Safety of laser products - Part 1: Equipment
Classification and Requirements, Corrigendum 1.
7. IEC 60825-1 (2nd edition - 2007) I-SH 01. Safety of Laser Products - Part 1:
Equipment classification and requirements, Interpretation Sheet 1.
8. IEC 60825-1 (2007) 2nd edition I-SH 02. Safety of Laser Products - Part 1:
Equipment classifcation and requirements, Interpretation Sheet 2.
9. IEC 62471 1st edition 2006-07. Photobiological safety of lamps and lamp systems.
10. IEC 60601-2-22, 3rd Edition 2007-05. Medical electrical equipment - Part 2-22:
Particular requirements for basic safety and essential performance of surgical,
cosmetic, therapeutic and diagnostic laser equipment.
ATLAS
Fig. 1: This lens is used for Qsw Nd:YAG 532 nm, with a rating of L6. The marking
DIRM indicates that it covers all pulse durations and wavelengths as specified (180315,315-532nm). This is according to the European rating standards (CE)
Fig. 2 :This lens is used for CO2 laser. Note the wavelength and the OD
Fig. 3: This eyeware is used for IPL
Fig. 4 : A laser safety label of a Class 4 laser (Er:YAG).Note the detailed

instructions,including type of laser and class
Fig. 5: A laser safety label of a class 2 laser
APPENDIX
Consent Form
Name
I understand that Dr
will perform
laser surgery
on my
(Specify location).
I understand laser surgery consists of removing/treating
.
I understand that despite the ability of the device to help ameliorate the skin
disorder, the following restrictions apply to the treatment:
1. The goal is improvement rather than perfection. There is no guarantee
that the anticipated results will be achieved.
2. There may be signicant swelling, oozing, and crusting, which may last
for 12 weeks (ablative lasers).
3. Improvement may continue as time elapses after treatment. The nal
result may not be apparent for up to 1 year (fractional lasers).
4. If additional improvement is desired after this time, it may be possible to
retreat areas.
5. Although pain management is a primary concern during treatment,
some mild transient discomfort may occur, especially stinging after
the procedure.
6. There is no guarantee that the results will be permanent. In rare cases,
the skin can even look worse than before treatment. This may or may not
be due to one of the complications or consequences of laser surgery.
I understand that the following complications, although infrequent, can
occur after laser treatment:
1. Scarring: This can occur in the form a raised or depressed red area with
change in skin texture. Over time these may turn white. It is important
that any prior history of abnormal scarring is reported.
2. Infection: Despite preventive measures, infection may occur, and
additional medications may be necessary for treatment.
3. Color changes: There is a risk of temporary or permanent dark or light
changes to the skin.
4. The likelihood of side effects will be decreased by my strict adherence
to written postoperative instructions. Besides caring for the wound,
avoiding sunlight exposure is critical, especially in the rst 12 weeks
after surgery.
I have read this form and have been given the opportunity to discuss any
questions I may have regarding the nature and aims of this procedure.
Doctor (Name)
Reg No.
Laser
FDA/CE/ISO
1. The risk, benefit and alternatives have been explained to the patient.
Yes/No

2. The type of anesthesia given will be
Oral/Topical/Infiltration
3. Permission for release of photographs with masking of identification

features has been taken
Yes/No
4. The patient has been informed about the right to revocation of consent.
Yes/No

5. A no guarantee clause is implicit and the patient has been made
aware that although the laser procedure is effective in most cases, no
guarantees can be made that a specific patient will benefit from the laser
treatment.
Yes/No

6. The patient has choosen to undergo another laser treatment with inferior
results, an informed refusal is appended.
Patient/Guardian Date
Surgeon Date
Witness Date
Yes/No
APPENDIX
Procedure Checklist
PREOPERATIVE CHECKLIST

1.
2.
3.
4.
5.
6.
7.
8.
Sign the consent form.

Verify patient name.
Verify procedure: Site, device.
Ask patient for drug allergies.
Review contradictions.
Ask patient if he has any queries.
Conrm pricing with patient.
Conrm laser or device parameters to be used set correctly. Also wipe
clean the lens and probes before starting the procedure.
9. Conrm protective eyewear.
10. Check for intraoperative cooling.
INTRAOPERATIVE CHECKLIST
1. Administer rst pulse: Examine and conrm correct tissue response.
2. Stop treatment if tissue response not appropriate
3. Check patient pain level: If too high, stop.
POSTOPERATIVE CHECKLIST
1. Apply appropriate postcare products.
2. Review and give patient discharge instructions.
APPENDIX
Postoperative Care
Though full face resurfacing is not done nowadays, a few basic principles
are useful to prevent complications for most laser procedures, specifically
ablative lasers.
COOLING
This is crucial to prevent pigmentation which is a issue in pigmented skin.
DRESSING
Open techniques with use of topical agents is practiced commonly though
in certain cases like, pyogenic granuloma, closed techniques and occlusive
dressings (with or without topicals) can be used.
SCAR PREVENTION/INFECTION CONTROL

Care should be taken immediately after completion of the procedure to
minimize the probability of scar formation and bacteria or viral infection.
Anti-inammatory and antibiotics/antivirals can be used early in the recovery
process to promote healing.
OVERVIEW OF POSTOPERATIVE CARE

For convenience we are adopting the approach of Davis and Perez. Some
of the interventions might seem aggressive and are essential if an ablative
procedure is underatken. The mention of brand names is only indicative and
does not indicate any endorsement.
1. First 2 Days
Interventions
Topicals/dressings, anti-inflammatory agents and antiseptic are needed. The
basic aim is to enhance healing, reduce swelling and infection prevention.
1. Cooling: It makes sense to ask the patient to carry a ice pack as posttreatment cooling helps to eliminate most of the side effects. Thus while
the patients procedure is being done the ice pack can be chilled which
the patient can use afterwards.
2. Moisturizers: Post-treatment moisturizers should be non-occlusive
in oily skin and occlusive in dry skin. Also it makes sense to use a
preservative free and fragrance free product. A simple thumb rule is
to use products, which are used for atopic patients as they satisfy most
of the requirements. The products that we use include Aloevera gel (40
50%) (ALoekem 75TM/Jula gelTM), CetaphilTM moisturizing cream, Physio
gelTM and if possible EucerinTM (Petrolatum 41%). The aim is to enhance
the healing and moisturized the skin.
One common problem seen in patients undergoing laser hair removal at
laser clinics is the presence of a low grade acne post laser.This is largely
due to the use of post-procedure creams promoted by the laser clinics
which contain comedogenic ingredients. Thus it is a useful step to check
the products for such ingredients (Box A4.1).
3. Antibiotics: Topical antibiotics are often used and we prefer fucidic acid
over mupironic acid. Oral antibiotics are given in ablative procedures
and we prefer Levoflaxacin 750 mg HS for 7 days.
4. Antinflammatory agents: If antinflamatory agents are needed, it is
better to use FucibetTM over FlutibactTM ointment as the latter is classified
as a class III steroid while fucibet is a class V steroid. Thus the side effects
are less with the former preparation.
5. Gentle washing with normal saline (0.9%) is ideal. Another option if
there is crusting is the use of hydrogen peroxide (5%) 1:1 dilution which
is an effective agent to remove crusts and prevent infection.
6. Dressing: In most procedures, an open dressing approach is employed
except in ablative procedures where a closed dressing is used.We do not
find any specific dressing to be superior for most routine cases.
Box A4.1 List of comedogenic ingredients in moisturizing cream

Facial moisturizer
Beeswax
Cetyl alcohol
Carbomer
Glyceryl stearate
Jojoba oil
Lanolin alcohol
Mineral oil
Myristyl lactate
PG Dicaprylate/dicaprate
Stearic acid
Triethanolamine
2. Next 3 Days to 1 Week

Interventions
The use of moisturizers, antibiotics,antivirals are needed to prevent scarring
and infection
The principles are same as above. The use of a mositurizer twice a day and
a antibiotic cream at night is adequate. The crusting should not be removed
manually to avoid scarring and post-inflammatory hyperpigmentation (PIH).
3. Next 14 Days
Interventions
Cleansers are used to remove crusting and cover and treat erythema. The
intermediate recovery period is a transitional period from the active healing
phase. If there is a hint of a scar formation, topical retinoids can be started.
We prefer RevizeTM (Tretinoin 0.20%).
4. Next 34 Weeks
Interventions
Sunscreens: Protection from UV is highly recommended as the epidermis
is regenerating and PIH if it occurs can mar any successful therapy.Because
of the initial ablation of melanocytes, the skin may not be fully capable of
photoprotection making it more susceptible to DNA damage.
A few principles should be practised.
1. Use a sunscreen which is not excessively greasy or that which contains
alcohol.
2. Always consider the patients skin type, an excessive oily, ingredient
rich sunscreen is rarely applied consistently as the sticky feel can make
compliance difficult.
3. A simple thumb rule is to use a physical block or a sunscreen with a mat
finish as ultimately a proper use is more important than no use at all !
Micronized titanium dioxide (Suncross softTM/Sunstop 19TM) is an ideal
sunscreen. Another option is to use a sunscreen with minimal ingredients,
as all the ingredients are lipid soluble and thus more the components more
oily the final sunscreen. Spectraban sensitiveTM that contains octinoxate
and Tinosorb M is an ideal chemical block. We do not prefer administering
sunscreens with multiple ingredients as there is a risk of allergenic sensitivities
more so when the epidermis is damaged.
Other measures like hats, protective clothing are useful as the substantivity
of sunscreens and duration are restricted,specially in tropical countries like
India.
5. Beyond 4 Weeks
Interventions
The most important intervention is bleaching agents to prevent pigmentation.
While most pigmentation issues resolve themselves, some may need
treatment or additional therapy to alleviate.
Depigmenting agents are conveniently classified into three types
(Table A4.1) below. It is our experience that, post laser a tretinoin or HQ
based cream or a triple combination preparation should be avoided. This
is as the tretinoin causes inflammation which perpetuates the PIH. For the
same reason the agenst that increase cell turnover should also be avoided.
The search for the ideal agent, entails a product that contains a tyrosinase
inhibitor more potent than HQ, which are azelaic acid, deoxyarbutin, dioic
acid, ellagalic acid, embilca and licorice. Thus a preparation with any of these
Table A4.1 Classication of depigmenting agents
Agents that act before
the stage of melanin
synthesis
Agents that act during melanin

synthesis
Agents that act after melanin

synthesis
Tyrosinase
transcription
C2-ceramide
Tretinoin
Tyrosinase inhibition
Azelaic acid
Arbutin
Hydroquinone
Kojic acid
4-hydroxy-anisole
Methyl gentisate
4-SCAP
Ellagic acid
Resveratrol
Aloesin
Oxyresveratrol
Tyrosinase degradation
Linoleic acid
a-Linolenic acid
Tyrosinase
glycosylation
PaSSO 3 Ca
Peroxidase inhibition
Methimazole
Phenols/catechols
Inhibition of melanosome
transfer
Niacinamide
Soybean/milk extracts
Serine protease inhibitors
L
ecithins and
neoglycoprotein
RW-50353
Product reduction and ROS

scavengers
Ascorbic acid
a -Toc F
Ascorbic acid
Palmitate D
L- a -Toc F
VC-PMG
Hydrocoumarins
Thioctic acid
Acceleration of skin turnover

Lactic acid
Retinoic acid
Glycolic acid
Linoleic acid
Liquiritin
can be an effective inhibitor of melanin synthesis. This in combination with an

agent that acts after melanin synthesis and does not cause irritation is ideal.
A list of such products is given in TableA4.2, though we prefer MelaglowTM or
DepiwhiteTM to prevent PIH.
Table A4.2 Overview of common hypopigmenting preparations in India
Brand
Agents that act before the

stage of melanin synthesis
Agents that act

during melanin
synthesis
Agents that act after

melanin synthesis
Melaglow
0.1 % THC
2% Kojic Acid
4%Niacinamide
0.2 % Soy
Isoflavanoid
Depiwhite
2%Kojic Acid
2% HQ
Vit C
Lactic acid
Vitis vinifera
Antipollon
Banatan
1% Mulberry extract
1% Deoxyarbutin
1% Licorice extract
Cosglo
Octinoxate
7.5 % w/w,
Kojic dipalmitate 2%
Arbutin 1.5 % w/w
Pinus-pinaster bark
extract 2%
Niacinamide 5% w/w
APPENDIX
Sample Operative Note
Procedure: CO2 Laser ablation (removal)

Indication: Adnexal tumor
Location: Face
PROCEDURE
1. The patient was counseled regarding the risks and potential benets of
the procedure.
2. Ninety minutes before surgery, a thick layer of EMLA cream was applied
to the treatment site. The cream was removed just prior to surgery.
3. The face was cleansed with savlon solution to include a 2 cm perimeter
of untreated skin.
4. The entire treatment area was surrounded with wet towels and the hair
was wetted with sterile saline.
5. Approximately 0.2 mL of 2% lidocaine with 1:1,000,000 epinephrine was
injected intradermally just deep to each lesion.
6. The lesions were treated with 175250 mJ with the UltraPulse laser.
The 1mm spot size was used to ablate the lesion to a level where only
stippled remnants of the base were observed.
7. Bacitracin/Fucidin ointment was applied, and written and verbal
postoperative instructions were provided.
8. The patient was asked to follow up in 710 days.
9. The patient was discharged from the clinic in good condition.
10. Oral antibiotics and a NSAID were given for 5 days.
APPENDIX
Sample Postoperative Instructions

(Ablative Lasers)
CONTINUOUS WAVE AND PULSED CO2 LASERS

1. Immediately after treatment, an antibiotic with or without a dressing
will be applied. Any dressing will be removed 12 days after treatment.
The dressing should be left alone until the next follow-up visit.
2. Avoid strenuous exercise for 10 days. Avoid unnecessary sun exposure.
3. There may be swelling after treatment, especially around the eyes (they
may even be closed shut for 1 day). This will resolve within 3 days. An
ice pack may be placed over swollen sites once the dressing has been
removed. This may be done as often as 510 minutes every hour while
awake.
4. Sleeping with your head elevated may reduce swelling.
5. For the next 13 days, the wound should be cleaned at home by applying
either normal saline or hydrogen peroxide solution a cloth or gauze.
After soaking with this for 1015 minute, any excess crusts can be
gently removed by using a cotton bud. Occasionally, pinpoint bleeding
may occur; this can be stopped by applying gentle pressure for several
minutes. After cleaning the wound, a petrolatum-type ointment or
antibiotic ointment should be applied.
6. Allow shower water to irrigate the wound but avoid use of soaps to the
open skin. Once the skin is healed (no open areas), your normal soap
may be resumed.
7. Please follow-up visits weekly for the rst 3 weeks after treatment.
8. In case of rash, fever, or severe pain please come back for a visit.
AFTER 1 WEEK
1. After 1 week normally, the skin will be healed enough for you to be
able to go outside. The face should be covered with a broad- spectrum
sunscreen (at least SPF 15) and the head covered with a broad-brim hat.
If your face is sensitive a physical block can be used. It is most important
to avoid any sun exposure as long as the skin is pink.
2. A concealer or a esh-tone foundation can then be applied.
3. A light non-comedogenic moisturizer can be applied ad lib (Cetaphil,
Secalia, Physio gel, Sebamed Clear gel).
4. Apply a steroid cream every night if your doctor prescribes it for redness.
APPENDIX
Patient Information Sheet
PATIENT INFORMATION SHEET (HAIR REMOVAL)

Which Methods of Hair Removal are Possible?
The various methods employed include, shavers, hair removal cream, wax
stripes,threading or electric epilating devices are mostly used.
These are only temporary methods of hair removal, and moreover the
electric epilation requires much effort.
Shaving is one of the most commonly applied procedure, but its result can
be seen only a few days and a post-treatment is continuously required to get
rid of unwanted hair.
The plucking of hair has a longer effect than shaving but it causes pain, is
used for smaller areas and can cause folliculitis.
The hair removal by using wax is similar to the plucking method and
allows the treatment of larger areas. Like hair plucking, the wax method can
also cause much pain and allergic reactions, inflammations of the hair bulb
in particular.
Lasers and flashlamps ensures a reliable, effective and relatively painless
removal of unwanted hair.
The possibility of a simultaneous treatment of several hairs that are close
together increases the effectiveness.
The laser/flashlamp has been designed for the selective destruction of the
hair roots so that a skin irritation known from the other methods is nearly not
caused.
Laser Hair Removal

The high-energy light penetrates the skin up to a depth of several millimeters,
passes the upper skin layer and the brown pigment (melanin) of the hair in
the skin absorbs the light energy specifically and converts it into heat. Thus
the cell layers (hair root and bulb region) surrounding the hair and being
responsible for the hair growth are heated so that they are permanently
damaged.
As the epilation by means of high-energy light is adjusted to dark

(pigmented) hair, red, blond or grey hairs respond less to it.
Hair grows in different phases. The single human hairs are in different
growth phases. The light energy only damages the hairs that are in an early
growth phase because afterwards the hair detaches from the hair root so that
the root is not heated any longer. Therefore, 6 or 8 sessions are required for
each person. A higher treatment repetition rate increases the probability to
strike each hair once in its sensitive growth phase.
The interval between the treatments should be 4 to 8 weeks and depends
on the treated part of the body. As long as hair has not grown again in the
treated area, a new session would not be useful because none of the hairs is
in the growth phase then.
The effectiveness mostly depends on the color, thickness and depth of the
hair as well as on the hormonal level and the genetic disposition.
The best effects can be reached, if the skin is not tanned and the hair is
dark. To avoid unwanted side effects, it is recommended to be as pale as
possible before the treatment or to start the treatment in winter, because
tanned skin also contains melanin in its upper layer.
Often, a hair removal of 100% cannot be achieved. In particular, fine and /
or light hair can remain.
Therefore, it is better to speak about a reduction of hair. Depending
on the genetic disposition and the hormones, new hair can grow from the
numerous sleeping bulbs in the skin after a longer period. In these cases, a
post-treatment is necessary, but not again a complete series of sessions.
What is the Treatment like?

After applying a water-containing gel, the system handpiece is positioned on
the skin and emits a light pulse that gives you a feeling of a slight prick. Then,
the handpiece of the laser is moved over the areas to be treated. The upper
skin layer is cooled simultaneously.
If one hour before the treatment an anesthetic ointment is applied, you do
not feel anything.
After the treatment skin reddening and/or a feeling of heat can be caused.
The release of tissue-active substances can cause little swellings around the
hairs. This phenomenon is particularly typical for very dark and thick hair. As
a whole, the side effects can be compared with slight sunburn.
The hair comes loose, loses its support and finally falls out. Particularly for
thick hair, this effect can be produced after only maximum 2 weeks. The hairs
growing again are mostly thinner and lighter than the original ones.
The next treatment can be performed after 4 to 8 weeks, if new hairs grown
in the meantime are visible.
What Aspects Must be Considered Before the Treatment?

Shave your hair to skin level one day before the treatment.
The treatment area should not be tanned.
Do not pluck your hair by means of pincers, wax or electric epilators for 46
weeks before the treatment.
If necessary, apply EMLA ointment on the sensitive areas 1 hour before
starting the treatment.
What Aspects Must be Considered After the Treatment?

Cool the area to be treated as long as you have a pleasant feeling.
Slight crusts can develop on sensitive skin and must not be manipulated.
Do not expose the treated area to the sun or intensive light (solarium)
without protection for at least 6 weeks.
If you observe skin irritations that have not been mentioned here, please
contact the doctor responsible for the treatment!
What the doctor should know:

What is your natural hair color?
What is your natural skin color?
Genetic lineage:
Are you tranned at present?
Yes No
Do you have allergies or hypersensitivity reactions, particularly against light?

if yes, which
Yes No
Do you take drugs at present?
If yes, which:
Yes No
Are you prone to skine diseases, e.g. acne, herpes simplex, psoriasis or difficult wound
healing?
if yes, which:
Yes No
Do you suffer from chronic or acute diseases?
if yes, which:
Which method have you used so far to remove
unwanted hair?
Epilation device Plucking Wax
Shaving Bleaching Creams
Electric epilation
Frequency:
Yes No
PATIENT INFORMATION SHEET (PIGMENTED LESIONS/TATTOO)

What Happens if You Get a Tattoo?
When a tattoo is made, a colorant is injected into the skin. These colorants are
partly simple Indian inks, but the tolerability of the inks that are often used
today has not always been thoroughly tested.
In such a procedure, the ink particles are implanted under the upper skin
layer (epidermis) in a depth of about between 0.5 and 2 mm.
During the healing phase, the bodys immune system tries to remove the
foreign substances.
As the ink particles cannot be metabolized directly by the body due to
their size, they are isolated from the surrounding tissue by a connective
tissue coating. Rest are removed by the lymphatic system. These rests can be
detected in the lymphatic system during all your life.
How Does a Laser Device Function?

A laser is a device that generates a defined light color with high precision and
focuses an extremely narrow light beam.
The effect of each light color is specialized to a specific skin structure so
that it is possible to remove unwanted skin changes without damaging the
tissue surrounding them.
The emitted laser light has a high power but is primarily absorbed by the
colorants of the tattoo, the dirt particles or the melanin.
Due to the specific absorption, the side effects are low and the healing
phase is short.
How Does the Laser Function in such a Treatment?

The laser beam penetrates the skin and the ink or dirt particles or the melanin
absorb the light energy.
The encapsulated ink particles or the melanin are/is promptly pulverized by
the mechanical effect of extremely short light pulses.
The split particles are removed by the lymphatic system. This process takes
time. Therefore, the subsequent sessions are only useful after several weeks.
What Is the Treatment Like?

First, your eyes are protected by a laser-protective eye-wear. The spacer of
the laser handpiece is positioned onto the skin and after the activation of the
laser via the foot switch a light pulse is emitted and you feel a slight prick.
Then, the handpiece of the laser is moved over the areas to be treated.
Each treated point looks white first, like a blister. This will vanish after
several minutes.
After the treatment reddened skin, a strong feeling of heat and / or

urtication can be caused. Dot-shaped bleedings cannot always be avoided.
After a few hours, the treated areas can become darker and minor crusts
develop and will disappear after several days.
The next treatment can be performed after 6 to 8 weeks. The number of
sessions depends on the amount of ink particles or melanin contained in the
skin and on the specific part of the body.
The tattoo cannot always be removed completely.
As the light energy is better absorbed by dark colorants, lighter particles
show less response to them.
In particular for color tattoos (e.g. permanent makeup) changes of
the color can also be observed and in rare cases they cannot be removed.
Therefore, try to give the doctor a sample so that it is possible to test the
properties of the injected colored ink even before the treatment.

1. The treatment area should not be tanned.
2. If necessary, apply EMLA ointment on the sensitive areas one hour
before starting the treatment.

1. Cool the area to be treated as long as you have a pleasant feeling.
2. Never manipulate crusts.
3. Do not expose the treated area without protection to the sun or intensive
light (solarium) for at least 6 weeks.
4. If you observe skin irritations that have not been mentioned here, please
contact the doctor responsible for the treatment.
PATIENT INFORMATION SHEET (VASCULAR LESIONS)

How Does a Laser/Flashlamp Treatment Works?
The high-energy light (of the laser/flashlamp) penetrates the skin and is
absorbed by the blood pigment hemoglobin. The absorbed energy heats
the blood vessel. This leads to the closure of the vessel. The duration of this
process depends on the size of the vessel: The larger the vessel the longer the
procedure (for deep bluish vessels the treatment can take some months).
Laser/flashlamps can emit different wavelengths (colors). As the blood
absorbs the green color particularly well, the green light is best suited for
small vessels that are normally red and superficial. But the water absorption
is very low. As the skin normally contains a lot of water, the surrounding skin
is heated only a little bit and not influenced by the light very much.
Therefore, the risk of scars on the skin is very low. Larger and deeper
vessels (mostly bluish) are to be treated preferably by infrared light that is
more effective because it can penetrate the skin deeper.
What is the Treatment Like?

This skin is cooled before the treatment. The larger the vessels and the area to
be treated, the longer the time required for cooling. Your eyes are protected
from the laser light by laser protective eye-wear or covered by light-proof eye
patches.
The doctor moves the handpiece over the area to be treated. You will
feel slight pricks that are a sign of the effectiveness of the therapy. Normally,
anesthesia is not necessary. The period of the treatment depends on the size
of the relevant area and is normally not longer than a few minutes.
Depending on the size of the lesion, reddening and swelling can be
observed after the treatment. In some cases, slight crusts can develop and
should never be manipulated.
Whereas fine red blood vessels of the face can be removed in 1 or 2
sessions, the removal of larger vessels of the leg is more difficult. The latter do
not always respond to the treatment. For other indications, it can be necessary
to perform more than just one session at intervals of several weeks.

1. You are not tanned in the area to be treated (no sun exposure for 4 weeks
before the start of the treatment). It is a good idea to initiate therapy in
autumn or winters.
2. You do not take drugs that inhibit blood coagulation (e.g. Aspirin).
3. The area to be treated is free of pathological findings (no inflammation,
suppuration, etc.).
Immediately before the treatment:

1. The area to be treated is carefully cleaned, cream and makeup are
removed.
2. If necessary, the area to be treated must be shaved carefully.

1. Cool the area to be treated as long as you have a pleasant feeling.
2. Possibly developed crust must not be manipulated.
3. Do not expose the treated area without protection to the sun for at least
6 weeks.
4. Avoid intensive physical exercises, hot bathes and do not go to the sauna
for 5 days after the treatment.
5. Prevent the skin from reddening by alcohol, hot spices or similar
substances.
6. If you observe skin irritations that have not been mentioned here, please
contact the doctor responsible for the treatment.

Are you prone to keloiding?
Yes No
Are you tanned at present?
Yes No
Do you have allergies or hypersensitivity reactions, particularly against light?

if yes, which
Yes No
Do you take drugs at present?
if yes, which
Yes No
Are you prone to skin deseases, e.g. acne, herpes simplex, psoriasis or difficult wound
healing?
if yes, which
Yes No
Do you suffer from chronic or acute diseases?
if yes, which
Yes No
For women: Could you be pregnant?
Yes No
Do you smoke?
if yes, how much:
Yes No
PATIENT INFORMATION SHEET (ABLATIVE LASERS/FRACTIONAL)

Which Skin Lesions can be Treated by Means
of an Ablative/Fractional Laser?
As one becomes older, the skin loses its elasticity and the connective tissue
shrinks. Wrinkles and also other irregularities of the skin surface develop.
Many of these changes can be treated by using ablative lasers, e.g.:
1. Stretching out minor wrinkles (no expression lines)
2. Skin lifting
3. Ablation of protruding scars
4. Stretching out acne scars
5. Ablation of keratinized tissue
6. Removing (benign) birthmarks
7. Removing cholesterol deposits around the eyes
8. Removing warts and other treatments.
For fractional lasers though there is a long list of conditions that
respond,acne scars, early photodamage and rejuvenation are the common
responsive disorders.
How does the Laser Ablation Function?

The lasers used for ablation have a wavelength (in the infrared range) that is
strongly absorbed by the water contained in the skin. In this way, the skin is
ablated pulse by pulse in an almost cold manner. Two different methods
exist for the ablation:
Ablative lasers (CO2/Er:YAG): In case of more intensive skin changes the
upper skin layer is ablated completely in the area to be treated.
Fractional Lasers: For skin rejuvenation it is also possible to apply a stateof-the-art procedure in which the upper skin is only ablated in a spot-like
manner (microspots). This method is called fraction ablation. In the fractional
ablation, a large part of the skin between the microspots remains untreated
and therefore less side effects are caused.

Your eyes are protected from the laser light; additionally you should shut
your eyes. The handpiece of the laser device is placed on the skin.
Ablative lasers (CO2/Er:YAG)
The unwanted lesion or the area to be treated is ablated precisely by removing
extremely thin layers by several light pulses per second with a spot size of few
millimeters.
The treatment of minor lesions, such as birthmarks or warts, takes only
a few minutes, larger areas require considerably more time. For larger areas
to be treated, a local anesthesia, seldom anesthesia, is necessary. Often one

treatment session is sufficient, but some indications require several sessions.
Fractional Lasers
Here only tiny microspots are ablated in the area concerned within the spot
having a size of about one square centimeter.
As this procedure is normally used for treating larger areas, e.g. the whole
face. This treatment can take a period of between a quarter and half an hour,
local anesthesia is normally not required. To achieve an optimum result it
can be necessary to perform more than one session at intervals of several
weeks.

You are adult. For women: You are not pregnant.
1. You are not tanned in the area to be treated.
2. You do not take drugs that inhibit blood coagulation (e.g. Aspirin).
3. The area to be treated is without pathological findings (no inflammation,
suppuration, etc.).
4. If an anesthesia is required, you will be informed separately.
1. The area to be treated is carefully cleaned, creams and make-up are
removed.

1. UV protection for the treated area for 12 weeks, in case of extensive
ablation of larger areas even longer.
2. For minor lesions: The area must heal without manipulation of the
crusts.
3. Do not do any works during which the treated area comes into contact
with dirt or dust.

Do you suffer from chronic or acute diseases? (including metabolic disorders, high blood
pressure)
if yes, which
Yes No
Do you have a cardiac pacemaker, implants or prostheses?
if yes, which
Yes No
Do you suffer from blood clotting disorders? (intensive bleeding of injuries, hematomas after
slight shocks)
Yes No
Could you be pregnant?
Yes No
Do you take drugs at present, e.g. anticoagulants such as Marcumar, Aspirin?

if yes, which
Yes No
Are you prone to keloiding?
Yes No
Do you have allergies, particularly against light?

if yes, which
Yes No
Do you have lip blisters (herpes) or acne?
Yes No
Do you often suffer from infections?
Yes No
Do you smoke?
Yes No
PATIENT INFORMATION SHEET (RADIOFREQUENCY)

What Does Skin Ageing Mean?
In the course of time, the skin loses its elasticity and strength, wrinkles
develop. Apart from the genetic disposition and hormones, this process is
also influenced by environmental factors, such as UV radiation or nicotine.
The net-like branched collagen fibers of the corium are damaged and partly
they lose their reproduction capability. The process of collagen reproduction
can be stimulated again by radiofrequency treatments. A firm skin and minor
wrinkles are the result. Several sessions are necessary to obtain an optimum
effect.
How Does a Radiofrequency Device Function?

In the radiofrequency therapy an intensive depth heat is generated. It tightens
the treated skin areas without damaging the surrounding tissue. When the
skin surface is cooled by the handpiece, the connective tissue is slightly
heated by the high-frequency RF current. This causes the contraction and
lifting of collagen. Simultaneously, the collagen reproduction is stimulated
and has an additional lifting effect after some weeks.
Immediately after the treatment you can go in for your normal activities.
How Does the Radiofrequency Treatment Function?

Radiofrequency power can generate heat within the skin. The heat intensity
depends on the power used and the duration of the RF current influence.
Depending on the individual skin resistance and water contents these
parameters can vary from one patient to the other. Therefore, a test treatment
is performed first to determine the optimum parameters.
The skin is soaked to the handpiece by low pressure and RF current is
specifically applied in the volume soaked in. In this process, high-frequency
waves are emitted between the electrodes. Simultaneously, the handpiece
ensures the cooling of the epidermis.
This procedure leads to a selective heating of the soaked-in skin and thus
the collagen is lifted.
The combination of radiofrequency and massage is generated by a
pulsating low pressure. Thus, the cell reproduction is stimulated additionally.
The described treatment method can be applied both for the face and for
the body.

The handpiece of the RF device is placed onto the skin. A defined proportion
of the skin is firmly soaked to the handpiece and radiofrequency is generated
at the same time. This process lasts some seconds and is repeated at the next
area then until the whole defined area is treated.
During the RF treatment a slight feeling of heat can be caused. If you feel
pain during the treatment, please inform the doctor immediately. Then, the
parameters will be reduced. It is not recommended to endure the pain.
To obtain an optimum result, several sessions are necessary, mostly 6 to 8.
A pause of 2 weeks should be kept between the treatments.

1.
2.
3.
4.
5.
6.
7.
8.
You are adult and healthy.

You did not undergo an operation during the last 4 weeks.
You did not get isotretinoin in an acne therapy during the last 4 weeks.
You are not pregnant.
You do not take drugs that inhibit blood coagulation (e.g. Aspirin).
You are not prone to keloids.
You are not prone to difficult wound healing.
The area to be treated is free of pathological findings (no inflammation,
suppuration, etc.).
Remove makeup and deodorant.
Before the treatment, a couple gel is evenly applied on the skin.

1.
2.
3.
4.
5.
If necessary, cool the treated area as long as you have a pleasant feeling.
Do not have a hot shower for one day.
Apply moisturizing cream, possibly an anti-inflammatory ointment.
Avoid sun exposure and solarium for one week after the treatment.
If you do not detect skin reactions apart from a slight reddening, you can
use makeup again.

Do you suffer from chronic or acute diseases? (incl. metabolic disorders, high blood
pressure)
If yes, which:
Yes No
Did you undergo operations or acne therapies during the last 4 weeks?
If yes, which:
Yes No
Do you have a cardiac pacemaker, implants or prostheses?
If yes, which:
Yes No
Are you prone to blood-clotting disorders? (intensive bleeding of injuries, hematomas after
slight shocks)

YesNo
Could you be pregnant?

YesNo
Do you take drugs at present, e.g. anticoagulants such as Marcumar or Aspirin, immunosuppressive agents?
If yes, which:
Yes No
Do you suffer from allergies?
If yes, which:
Yes No
Are you prone to keloiding, bad wound healing or atrophy?

YesNo
Do you suffer from skin inflammations, open wounds or dry skin?

YesNo

Diagrammatic representation of areas to be treated
APPENDIX
Local Anesthetics
LIDOCAINE
Lidocaine, an aminoethylamide, is the prototypical amide local anesthetic.
Mechanism of Action
Local anesthetics block conduction in nerves by minimizing or preventing
the influx of sodium ions, thereby preventing depolarization. The type C pain
and itch fiber nerve conduction are blocked.
Pharmacology
Onset of action <2 hours; Protein binding 6080%; Eilimination T: 1.52.0.
Without epinephrine, the approximate duration of action of lidocaine is 3060
minutes while with epinephrine, this duration is about 120360 minutes.
Absorption and Distribution

Skin and subcutaneous tissues of the face and scalp exhibit higher significant
absorption than the trunk or extremities owing to the increased relative
density of blood vessels.
The majority of the drug passes through the liver, where it is metabolized,
and then is excreted into bile. Because very few metabolites are found in
feces, it is believed that the lidocaine metabolites are then reabsorbed from
the gastrointestinal tract and excreted in the urine.
Lidocaine metabolites represent the majority of excreted drug, with <10%
of the injected lidocaine being excreted unchanged by the kidney.
Clinical Use in Dermatology

Infiltrative anesthesia
Regional nerve blocks
Tumescent anesthesia
Postherpetic neuralgia
Usage Guidelines
Infiltration
The technique of infiltrative anesthesia involves injecting anesthetic directly
into and surrounding the area to be treated. Papillary dermal injection is most
painful and creates more tissue distortion, but gives nearly instantaneous
anesthesia. Such a depth of injection may be indicated in situations that
require very rapid onset of anesthesia. Subcutaneous is the least painful
plane of injection; however, this depth of injection provides less effective
anesthesia for epidermal and dermal procedures, unless the anesthetic is
allowed to diffuse into adjacent tissue planes over several minutes.
A favored method of infiltration involves injecting anesthetic slowly as the
needle is advanced into the deep dermis at the junction of the subcutaneous
tissue. This method strikes a balance between the previously discussed
methods, allowing relatively rapid onset of anesthesia with less injection
pain.
Special Considerations
Measures to Reduce Pain
1. Pinching the skin before and during injection.
2. Using a 1-inch needle.
3. If additional punctures are required, they may be made through
previously anesthetized skin.
4. Injecting from within a laceration or surgical wound edge than intact
skin.
5. Using a 30-gauge needle also minimizes the pain of injection (but
this needle size makes aspirating before injection (to confirm the
extravascular location of the needle) difficult.
6. Ice applied topically for 10 seconds affords 2 seconds of analgesia
7. A slow rate of injection is often less painful as well.
8. Buffered lidocaine with epinephrine (adding bicarbonate to anesthesia).
9. Use of pH-buffered lidocaine has been reported to reduce the pain of
injection in controlled studies. The most commonly used method for
buffering is to mix 1 part sodium bicarbonate (8.4% or 1mEq/mL) with
9 or 10 parts of 1% lidocaine with epinephrine 1:100000.
10. Warming the anesthetic to 40 C.
11. Adding hyaluronidase to lidocaine results in enhanced tissue dispersion
of lidocaine and less tissue distortion.
12. Hyaluronidase may also increase the pain of injection and reduce the
duration of anesthesia, whereas the long-term effects on wound healing
have not been evaluated. It also contains thimerosal, to which patients
may be allergic.
Adverse Effects
Common
Infiltration Anesthesia
Hematoma, ecchymosis, nerve laceration, or infection
Vasovagal reactions: Diaphoresis, lightheadedness, hypotension and most
importantly bradycardia.
(Immediate measures to treat such a reaction include supine positioning
with leg elevation (Trendelenburg position), smelling salts, and a cool
moist towel to the forehead. For vasovagal reactions not responding to
these measures, atropine 0.4 mg delivered subcutaneously has been
recommended).
Topical Agents
Erythema and pigmentation of the upperlip in a child after local dental
infiltration of lidocaine was attributed to a type of fixed drug eruption.
Erythema may also occur after topical use of some lidocaine formulations,
such as transdermal patches, while transient blanching of the skin is frequent
after application of eutectic lidocaine/prilocaine mixtures to the skin.
Rare
A summary of the manifestations of toxicity are given in Table A8.1 while the
detail are discussed below.
CNS Toxicity
Drowsiness, circumoral paresthesia, lingual paresthesia, tinnitus, nystagmus,
ataxia, hallucinations, twitching, restlessness, seizures, coma, or apnea. It
is important to note that the clinical signs do not necessarily progress in
this sequence. For example, if a large volume of lidocaine is delivered
intravascularly, seizures may be the first sign of toxicity noted.
Table A8.1 Summary of the manifestations of toxicity

Lidocaine toxicity (g/mL)
Symptoms
15
Tinnitus, lightheadedness, circumoral numbness, diplopia,

metallic taste in the mouth
58
Nystagmus, slurred speech, localized muscle twitching, ne

tremors
812
Focal seizure activity, which may progress to tonic-clonic

seizures
2025
Respiratory depression which can lead to coma
Complicating matters is the overlap between the signs and symptoms

of lidocaine toxicity and the systemic effects of epinephrine. Anxiety,
restlessness, and tremor may be due to significant systemic levels of either
drug. Given that the lidocaine dose limit has not been exceeded, these
signs and symptoms can be safely assumed to be from the epinephrine. The
absence of tinnitus and circumoral paresthesias also supports the diagnosis
that the above effects are indeed due to epinephrine.
Management: Treatment starts with recognition of the anesthetic toxicity,
discontinuing further use of local anesthetics, and observing for progressive
symptoms of lidocaine toxicity.
If clinical signs and symptoms of toxicity suggest midrange toxic blood
levels (58 mg/mL), treatment may be best accomplished by admission to
hospital for observation.
Seizures are treated by the following steps: Establishing an airway,
delivering oxygen, administering lorazepam or diazepam, and simultan
eously activating the emergency medical services (EMS).
Intravenous lipid emulsion (20%) infusion has been used safely and
effectively to improve survival and reverse the cardiovascular and neurologic
symptoms of local anesthetic toxicity.This agent is typically administered in
the emergency room or hospital setting.
CVS Toxicity
With lidocaine there is a progressive deterioration, with increasing blood
levels going from hypotension (due to sympathetic blockade), to bradycardia,
and finally respiratory depression.
Allergic Reactions
They may be due to the anesthetic itself (true anesthetic allergy) or to
preservatives such as parabens and sulfites.
The two types of allergic reaction to local anesthetics are anaphylactic
reactions (type I) and delayed-type hypersensitivity reactions (type IV).
The most serious are anaphylactic reactions, which may be lifethreatening. These reactions are mediated by immunoglobulin E (IgE) and
are often heralded by urticaria, angioedema, and bronchospasm (wheezing).
If these signs occur within 12 hours of anesthetic injection, they support the
diagnosis of anaphylaxis.
A practical clue for assistance in rapidly distinguishing anaphylactic
hypotension (in the absence of skin findings) from vasovagal reactions or
dysrhythmias is the pulse. In anaphylaxis the patient is tachycardic, whereas
in vasovagal reactions the patient is bradycardic, and finally in dysrhythmias
the pulse is irregular.
If the patient develops signs of respiratory or hemodynamic compromise,
the EMS should be activated as supportive measures are instituted.
The practice of simply switching classes in patients with anaphylactic

reactions has been recommended by some to avoid future hypersensitivity
reactions. Unfortunately, this class switching has never been proved to be
completely safe with regard to anaphylactic reactions.
Special Groups
Pregnancy: Category B
Lactation: American Academy of Pediatrics considers that it is usually
compatible with breastfeeding.
Renal: Unaffected in patients with renal failure.
LIDOCAINE AND TETRACAINE

(TetralidTM) 7%/7%
Classification
This is a topical local anesthetic cream that forms a pliable peel on the skin
when exposed to air. The drug formulation is an emulsion in which the oil
phase is a 1:1 eutectic mixture of lidocaine 7% and tetracaine 7%. The eutectic
mixture has a melting point below room temperature and therefore both
local anesthetics exist as a liquid oil rather than as crystals.
Chemical Class
Mechanism of Action: Lidocaine is an amide-type local anesthetic agent and
tetracaine is an ester-type local anesthetic agent.
Mechanism of Action
Both lidocaine and tetracaine block sodium ion channels required for the
initiation and conduction of neuronal impulses which, in certain instances,
results in local anesthesia.
Pharmacology
Duration of analgesia was evaluated using a pinprick test in 40 adult
volunteers.
The median duration of analgesia was 11 hours. There was no difference
between the 30-minute and 60-minute application periods with respect to
the mean for time to return of sensation. However, 55% of PliaglisTM treated
subjects still reported diminished sensation at the end of the 13-hour study
period.
Usage Guidelines
1. Pulsed dye laser therapy: 20-minutes application.
2. Non-ablative laser facial resurfacing and dermal filler injections: 30.
3. Laser-assisted tattoo removal: 60-minutes application (minimum time
of application).
4. The mean depth of analgesia has been measured to at least 6.8 mm.
5. The product manufacturer states that the patch should be placed on
intact skin 30 minutes before supercial dermatologic procedures such
as a shave biopsy.
Important Note
S-caine peel and S-caine patch: An S-caine peel, marketed as pliaglis
(Galderma Laboratories, Fort Worth, TX), was discontinued in September
2008. This product was a novel eutectic mixture of 7% lidocaine and 7%
tetracaine in a cream base. After application to the skin, the cream dried and
formed a exible lm that xed the anesthetic into position until the lm was
peeled off the skin. It was believed that the exible lm served as an occlusive
dressing that facilitated drug absorption or deposition into the skin. S-caine
peel was eventually terminated because of an inability to obtain consistent
product viscosity. Plans for its re-release are unclear.
The S-caine patch (Zars, Inc, Salt Lake City, UT) contains a small amount
of topical anesthetic under a patented heating element that raises the
temperature to 40C for longer than 14 hours and enhances delivery of the
anesthetic. This product is marketed as Synera and contains a eutectic mixture
of 70 mg of lidocaine and 70 mg of tetracaine. The heating system portion of
the patch is activated through an exothermic reaction when oxygen interacts
with the internal components of iron powder, activated carbon, wood our,
sodium chloride, and water. When the patch is applied to the skin, it increases
the skin temperature approximately 5C, but the maximum skin temperature
produced by the patch at the site of application does not exceed 40C.
EUTECTIC MIXTURE OF LOCAL ANESTHETIC (EMLA)

Eutectic mixtures: A cream containing lidocaine 2.5% and prilocaine 2.5%
as a eutectic mixture can produce local anesthesia when applied topically
to intact skin. Mixing the crystalline forms of each in a 1:1 ratio gives this
combination a lower melting point than either agent alone; this is known as
a eutectic mixture.
Chemical Class
Both are amides.
Prilocaine (CitanestTM) is an intermediate-acting amino amide that is

pharmacologically similar to lidocaine, except that it causes little vasodilation
and thus can be used without a vasoconstrictor if desired.

Systemic absorption of both drugs from the eutectic cream appears to be
minimal across intact skin 6 even after prolonged or extensive use.
The amount of EMLA systemically absorbed is directly related to the
duration and surface area of application. Skin blood flow, skin thickness
(especially the stratum corneum), and the presence of skin pathology lead to
altered absorption, in addition to affecting the onset of action, efficacy, and
duration of action of EMLA.Regional variation in absorption has also been
noted, with faster absorption occurring on the face.
Prilocaine is metabolized by hepatic microsomal CYP enzymes in a
fashion similar to lidocaine, but at a faster rate. Extrahepatic metabolism has
been suggested by animal experiments. Prilocaine is excreted as metabolites
via the kidney, with <1% of the drug renally excreted unchanged.
Pharmacology
Onset of action: < 1 hour
Peak effect: 23 hours
Duration: 2 hours after removal
The onset and duration of the effect may be affected by the site of
application. When used for the removal of genital warts an occlusive dressing
is not necessary and the application time recommended by the manufacturer
is 5 to 10 minutes. The level of anesthesia begins to decline after 10 to 15
minutes when applied to the genital mucosa and any procedure should be
started immediately.
Clinical Use in Dermatology

1. Topical analgesia for intact skin prior to surgery
2. Laser surgery
3. Mucosal analgesia
4. PHN
5. Pruritus
6. Premature ejaculation.
Usage Guidelines (Box A8.1)

Apply thickly under occlusion of a polyurethane dressing
Minimum time under occlusive dressing:
At least 60 minutes (genital mucosa 15 minutes)
Children: 1 to 5 years, 30 minutes

Box A8.1 Application of EMLA
Application and clinical use
1. Patients can apply the topical anesthetic before arriving at the ofce, assuming they
have proper instructions on its safe application
2. Safe application entails gently washing the area to be treated with a mild cleanser and
water
3. Patients should avoid skin cleansing with benzoyl peroxide, which may decrease the
topical anesthetics absorption
4. Patients may use a tongue depressor or gloved nger to apply a uniform layer of cream
approximately 1/8" thick. If the product is applied with a bare nger, the anesthetic
should be immediately washed off the digit once adequate application to the desired
area occurs
5. Depending upon the anesthetic used, the product is left in place for 30 to 60 minutes.
Occlusion with plastic wrap or massaging the cream into the skin may achieve quicker
onset of action, if necessary
6. Immediately preceding the procedure, the material is removed with dry gauze, and the
skin is wiped clean with water-dampened gauze. Complete removal of residual cream
before laser procedures is particularly important with alcohol-containing topical
anesthetics because of their incendiary potential
7. It must be emphasized to the patient that improper product use can result in dire
adverse events
Duration of effects:
Application
1.5 hours: Lasts for 30 minutes
2 hours: Lasts for 60 minutes
Loss of anesthesia: 90 minutes after removal
Maximum application time: 5 hours
Quantity: 12g/10cm2 (maximum 10 g)
Depth of analgesia:
1. Increases with increasing duration of application. After 60 minutes:
3mm; 120 minutes:5 mm
Special Considerations
1. Avoid on wounds or mucous membranes (except for genital warts in
adults)
2. Avoid in atopic dermatitis
3. Avoid near the eyes because it causes corneal irritation
4. Caution with anemia or congenital or acquired methemoglobinaemia.
Patients older than 7 years who weigh more than 20 kg should use no more
than 20 g of EMLA applied to their skin and covering no more than 200 cm2
of surface area for less than 4 hour. The U.S. Food and Drug Administration
(FDA) issued a public health advisory in 2007 reporting at least two instances
of death when young women applied topical anesthesia under occlusion to
their legs before laser hair removal. The advisory recommended that patients
use only FDA-approved topical anesthetics with the lowest concentration
of anesthetic for the shortest amount of time necessary. Because the risk of
adverse events with improper application is real and could lead to subsequent
medicolegal action, physicians must exercise caution and good judgment
when educating patients on home use of topical anesthetics. If a large area of
skin is involved, treatments should be divided into smaller anatomic portions
so that appropriately sized segments of skin are anesthetized and treated
during each session.
Adverse Effects
After application on the skin, EMLA produces a biphasic response with initial
vasoconstriction and blanching that peaks after 90 minutes of application.
After 2 to 3 hours of application, a rebound vasodilation occurs that results
in skin erythema, which should not be confused with other rare adverse
cutaneous reactions such as contact urticaria or allergic contact dermatitis. It
appears that prilocaine is the agent that plays a role in allergenicity.
Use on damaged or inamed skin or on a large surface area (2,000 cm2)
may increase the risk of systemic side effects.
Common
1. Transient paleness, redness, and edema
2. Stinging, burning, pruritus, and contact urticaria.
Rare
Skin
Purpura, petechia and allergic contact dermatitis to the prilocaine component
of EMLA cream has been reported.
Methemoglobinemia
The most serious adverse effect of EMLA is methemoglobinemia. This
is a unique adverse effect of prilocaine. In this condition a metabolite of
prilocaine, O-toluidine, is thought to cause oxidation of hemoglobin to
methemoglobin. This oxidized (ferric) form of hemoglobin cannot carry
oxygen and makes the release of oxygen from normal ferrous hemoglobin
less efficient. The final result is tissue hypoxia.
When levels of methemoglobin are between 15% and 30%, patients
present with initial signs of cyanosis. Methemoglobin levels of 30% to 50%
result in dyspnea, tachycardia, and headache. Methemoglobin levels greater
than 50% are associated with lethargy and coma.
Methemoglobinemia either resolves spontaneously or in severe
symptomatic cases can be hastened by IV administration of methylene blue.
Special Groups
Children
There has been concern that excessive absorption (particularly of prilocaine)
might lead to methemoglobinemia, and UK licensing information
recommends that the eutectic cream not be used in children less than 1 year
old. However, there seems to be little evidence of this, and the BNF considers
that it may be used under specialist supervision in infants over 1 month of
age (Table A8.2).
Table A8.2 Guidelines for use of EMLA in the pediatric population

Age and weight
Maximum dose (g)
Maximum area (cm2)
Maximum application
time (hours)
Up to 3 months or 5 kg
10
312 months and

510 kg
20
16 years and 1020 kg
10
100
712 years and >20 kg
20
200
APPENDIX
Select Bibliography
A book is worth the bibliography and this book stands on the shoulders of
legendary authors who have written some brilliant books on lasers. Of all the
books, my favourite remains the book by Mitchel P Goldman, which I believe
is one of the finest books on lasers. The newer technologies like, fractional
lasers, non-surgical sculpting and USG require a up-to-date text which is
provided by the voluminous book by Dr Keyvan Nouri and the concise book
by Dr Raulin and Dr Karsai. Some of the other books on lasers are also listed
below.
BOOKS
1. Laser and IPL Technology in Dermatology and Aesthetic Medicine.
Raulin C, Karsai S (Eds). London: Springer Heidelberg Dordrecht; 2011.
2. Lasers in Dermatology and Medicine. Nouri K, (Ed). London: Springer
Heidelberg Dordrecht; 2011.
3. Principles and practices in Cutaneous Laser Surgery. Editor, Arielle
Kauvar ANB; Associate Editor, Taylor and Francis; 2005.
4. Goldman MP. Cutaneous and Cosmetic Laser Surgery. Ist edn.
Elseiver; 2006.
5. Cutaneous Laser Surgery. 2nd edn. Goldman MP, Fitzpatrick RE (Eds).
Elseiver USA; 1999.
6. Hruza GJ, Avram MM. Lasers and Lights: Procedures in Cosmetic
Dermatology, 3rd edition; 2013.
JOURNALS
It is worthwhile to refer to journals some of which I have detailed in Box A9.1.
Though some excellent specialty journals exist, if there is a novel procedure
that you wish to publish, probably it will be a good idea to choose a journal
with a high impact factor ! The second list (Box A9.2) is the list of the top
indexed journals and the marked journals are those where most of the laser
articles are published.

Box A9.1 Select Laser and cosmetology journals
1.
Dermatologic Surgery Impact Factor: 1.866
2.
Facial Plastic Surgery Impact Factor 2012: 0.924
3.
Ind J Dermatol Venereol Impact Factorfor 2012 is1.206
4.
J Clin Aesthet Dermatol Awaited
5.
J CosmeticLaserTherapy Impact Factor 2012: 0.87
6.
J Cosmetic Dermatology Impact factor 0.87
7.
J Cutaneous Aesthetic Surgery Awaited
8.
J Cutaneous Medicine and Surgery Impact factor 0.783
9.
Laser in Surgery and Medicine Impact Factor: 2.455
10.
Lasers in Medicine and Science Impact Factor 2.402
11.
Laser Therapy: Impact factor Awaited
Box A9.2 Top ranking dermatology journal

Rank
Journal
Impact Factor
1.
J Invest Dermatol
6.193
2.
Pigm Cell Melanoma Res
5.839
3.
J Am Acad Dermatol
4.906
4.
Arch Dermatol
4.792
5.
Br.J Dermatol
3.759
6.
Exp Dermatol
3.578
7.
J Dermatol Sci
3.52
8.
Acta Derm- Venereol
3.487
9.
Contact Dermatitis
2.925
10.
Skin Pharmacol Phys
2.885
11.
Wound Repair Regen
2.757
12.
Arch Dermatol Res
2.708
13.
J Eur Acad Dermatol
2.694
14.
Melanoma Res
2.518
15.
Semin Cutan Med Surg
2.362
16.
Clin Dermatol
2.341
17.
Dermatology
2.024
18.
Dermatol Ther
1.963
19.
Dermatol Surg
1.866
20.
Am J Clin Dermatol
1.844
21.
Burns
1.799
22.
J Cutan Pathol
1.766
23.
J Dermatol
1.765
Contd...
Contd...
24.
Eur J Dermatol
1.756
25.
Int wound J
1.6
26.
Dermatol Clin
1.522
27.
Photodermatol Photo
1.516
28.
J Dermatol Treat
1.504
29.
Adv Skin Wound Care
1.5
30.
Am J Dermatopath
1.418
31.
Skin Res Technol
1.409
32.
J Dtsch Dermatol Ges
1.403
33.
Int J Dermatol
1.342
34.
Clin Exp Dermatol
1.329
35.
Mycoses
1.278
Laser and Medical Devices (Index)
Page numbers followed by f refer to figure and t refer to table
Alma lasers (http://www.almalasers.com)

184, 186, 271, 296t, 313
Ascepelion (http://www.ascepelion.com)
45f, 104t, 233f, 258
BTL Aesthetics (http://www.btlaesthetics.com)
297t, 314
Candela/Syneron (http://www.candelalaser.com)
296t, 309, 311,
CoolTouch Corp (http://www.cooltouch.com)
175
Cutera (http://www.cutera.com)
182t, 285, 315, 403
Cynosure (http://www.cynosure.com)
38, 175, 180t, 340t, 343, 349
Deka (http://www.dekalaser.com)
182t, 183,188,
Dynatronics (http://www.dynatronics.com)
340t
Elem Medical (http://www.smoothshapescolorado.com)
340t, 350,
EndyMEd Medical (http://www.endymed.com)
297t
Erchonia Medical (http://www.erchonia.com)
343t
GSD Tech Co (http://www.gsdaesthetic.com)
296t
HairMax (http://www.hairmax.com)
399, 401t, 489
Hoya ConBio (http://www.conbio.com)
104t
Invasix (http://www.invasix.com)
297t, 397t
Lasering (http://www.laseringusa.com)
182t
Light Age (http://www.lightage.com)
403
Lumenis (http://www.lumenis.com)
104t, 186, 370, 455, 483
Lutronic (http://www.lutronic.com)
182t,
Medicis (http://www.medicis.com)
343t
Mosaic (http://www.nu-reflection.com/medical_aesthetic/
mosaicresurfacing.html)
176, 212t
Nuvolase (http://www.nuvolase.com)
403
Palomar (http://www.palomarmedical.com)
104t,181t, 186
Pelleve (http://www.pelleve.com)
296t, 313
Pollogen (http://www.pollogen.com)
296t, 346
Protocadmus (http://www.protocadmus.com
104t, 177, 180t
Quantel (http://www.quantelmedical.com)
284
Sciton (http://www.sciton.com)
38, 181t, 403,
Sellas (http://www.sellaslaser.com)
181t
Solta Medical (http://www. www.solta.com)

230, 296t, 300, 343t
Sunetics International (http://www.sunetics.com)
399
TruSculpt (http://www.trusculpt.com)
296t
Ulthera (http://www.ultherapy.com)
294, 322, 333, 377t
UltraShapeLtd (http://www.syneron-candela.com/int/product/ultrashape)

321, 331, 348,
Venus Freeze (http://www.venusconcept.com)
297t
Viora (http://www.viorareaction.com)
297t,
Zeltiq Aesthetics (http://www.coolsculpting.com)
356
Index
Page numbers followed by f refer to figure and t refer to table
A
Ablative fractional CO2 laser 367
Ablative fractional resurfacing (AFR) 23,
177, 367
fractional carbon dioxide lasers 177
deka system 183
Lumenis superPulse 178 179f
Lumenis ultraPulse,178, 179f
solta device 177
fractional erbium:YAG lasers 177, 183
Almas fractional 183
fractional erbium:YSGG laser 184
Palomars fractional 183
Sciton 183
in hypertrophic scars 367
Ablative lasers 368, 422
absorption spectrum of 26
and fractional lasers, comparison of
173t, 173f
excisional surgery/debridement,
hair transplants 83
keloids 83
nail matrixectomy 82f
in acne keloidalis nuchae 63
in actinic cheilitis 64
in atrophic scars 368
in balanitis xerotica obliterans 85
in benign tumors 71, 72, 73
in chondrodermatitis nodularis
helices 85
in compound nevi 71
in dermal nevi 71
in epidermal nevi 67, 93f
in excisional surgery/debridement 81
in genital lichen planus 85
in granuloma faciale 85
in keratoderma 85
in kraurosis vulvae 85
in lichen sclerosis et atrophicus 85
in lupus erythematosus 85
in lymphangioma circumscriptum 84
in melanocytic nevi 70
in nevus sebaceous 70
in oral florid papiliomatosis 85
in porokeratosis 85
in psoriasis 85
in pyogenic granuloma 84, 84f
indications of 39, 60
limitations of 47
scars 60
acne/chickenpox 60
post-traumatic and surgical 62
ultraPulse lasers 75
vitiligo surgery 84
warts 77
condylomata 79
periungual 79
plantar 78, 80
Zoons balanitis 85
Acetaminophen 243
Acne 40, 379
Acne scars 91, 204, 209, 210t, 211t, 214t,
433
boxcar scars 207
controversies and new aspects 477
ice pick scars 206
rolling scars 204
Acne therapy 489
Acoustic waves 357
indications 357
used for local fat deposits 357

Acquired bilateral nevus of Ota like
macules (ABNOM) 156
Acquired melanocytic nevi 136
role of various lasers in 140
Activin 399
Adenoma sebaceum 71, 72
Adipocyte 341, 342
Alexandrite laser 10, 20
Alleviate chronic folliculitis 222
Alma device 344
Alopecia areata 227, 399
Alpha-hydroxy acid lotions 109
Aluma 311
Amateur tattoo 113
Aminolevulinic acid (ALA) 271
Anesthetic creams 262
Angiokeratomas of Fordyce 407
long-pulsed Nd:YAG lasers 407
pulsed dye laser 407
Angiolymphoid hyperplasia with
eosinophilia 384, 385
copper vapor laser 385
Arbitration 452
Arbutin 152
Argon laser 236, 238, 241
Arolling scars 204
Arrhenius 15
Asodilation 35
Aspect ratio and depth 476
Atrichoepitheliomas 71, 75
Atrophic scars 362, 367
Autoimmune connective tissue
disorders 261
Aversian response 497
Axillary hyperhidrosis 487
B
Basal cell carcinoma/squamous cell
carcinoma 410
ablative lasers 410
Nd:YAG 410
PDT and similar approaches 410
Beckers nevus 108, 135, 135f
Er:YAG laser 135
QS Nd:YAG laser 135
QS ruby laser 135
Bipolar radiofrequency 280, 343, 344
devices 278
Body contouring,
devices 336
persistent erythema in 337
pulmonary embolism in 337
thrombophlebitis in 337
Body mass index 342
Boxcar scars 207
C
Caf au lait macules, 133
QS alexandrite lasers in 133
QS Nd:YAG in 133
QS ruby in 133
Caf au lait patches 108
CALM 109, 112f , 137, 138
Carbon 12
Carbon dioxide lasers 25, 30, 63, 86, 105
comparison of 27, 29
comparison with Er:YAG lasers 36,
37f
continuous-wave type 25
Cw repeat mode 53, 53f
end points 46
minimum thermal damage in 53f
paintbrush technique 94f, 96f
postoperative care 87, 95f
preoperative regimen 86
principles of 26
simple rules 32
superPulse type 27
technique tips 30
thermal diffusion in 26
types of 27
types tissue damage in 26
UltraPulse mode 52, 53f
UltraPulse type 26, 28
Cellulaze 350
Cellulite 337
simple scoring system 339
treatment
focused ultrasound 339
methylxanthines 339
nonablative laser devices 339
retinol 339
therapeutic modalities 340t
Chickenpox scars 40
Chromophore 12, 14, 17, 21, 101
absorption spectra 12f, 22
Index 545
fat 12
hemoglobin 4, 12
melanin 4
penetration 12f
water 4
Civil and criminal negligence 444
CO2 10,600 nm 138
CO2 laser and Erb:YAG laser comparison
435t
Cobb syndrome 239
Collagen 13
contraction 87
remodeling 204
Collagenesis 282
Colloid milium 227
Combination laser therapy 126
Combination therapy 147t
Combination therapy with TC creams
148t
Combined-mode erbium YAG/CO2 laser
system 368
Complications and their management
455
Concomitant therapy 127
Congenital dermal melanocytosis 156
Q-switched alexandrite laser in 156
Congenital melanocytic nevi 141
ablative lasers with pigment lasers
in 141
pigment laser in 141
surgical excision followed by Er:YAG
in 141
Corticosteroids 109, 366
Cutting mode 58
Cryosurgery 65, 66
Cryotherapy 236
Cw CO2 17, 69
ultrapulse, comparison 29
Cw laser 64
Cynosure 350
D
Damage 446
Darier disease 385
carbon dioxide laser 385
combination of Er:YAG and CO2
386
Debulking surgery 248

Defocused mode 54
In exophytic lesions 54
in rhinophyma 55
in warts 54, 55
Deoxyribonucleic acid 12
Dereliction of duty 446
Dermabrasion 65
Dermal collagen fibers 36
Dermal heating 38
Dermal laser 106, 107
Dermal remodeling 276
Dermal tumour ablation 35
Dermatomyositis 386
argon lasers in 386
pulsed dye lasers in 386
Desmoglein 399
Diode lasers 12
Dirt tattoo 113
Direct causation 446
Disseminated granuloma annulare 227
Drug-induced hyperpigmentation 158
Dye lasers 5, 12
Dyschromias 222, 286
Dyspigmentation 41
E
Eczema 386
PDL in 386
Elastinogenesis 282
Elastosis perforans serpiginosa 386
Er:YAG laser in 386
pulsed carbon dioxide in 386
Electromagnetic spectrum 34
Electrosurgery 65
ELOS 312
eMatrix 312
Endogenous porphyrins 379
Ephelides 134
Epidermal disorders 131
IPL 132
lasers used in 132
lentigines in 131
milisecond devices in 132
Qsw devices in 132
Epidermal growth factor (EGF) 399
Epidermal laser 106, 107, 108t

Epidermal nevi 436
Epithelioma adenoides cysticum 381
Er:YAG 2940 nm 138
Erbium laser 432
lower depth of ablation 432
thermal damage 432
Erbium peel 41
Erbium:doped yttrium-aluminiumgarnet (Er:YAG) laser 16
Erbium:glass laser 6, 11, 17, 22, 32, 47,
62, 73, 78, 88
1535 nm 175
1540 nm 175
1550 nm 175
in acne scar 211t, 214t
Erbium:YAG laser 6, 11, 17, 22, 32, 47,
62, 73, 78, 88, 105, 368, 381, 383, 418
combination of 37
conventional 33
Gaussian laser beam profile 34
in junctional nevi 39
in sebaceous hyperplasia 39
in seborrheic keratoses 39
in solar keratoses 39
in trichoepithelioma 39
intraoperative dose/depth 90
intraoperative end point 90
intraoperative postoperative care 91,
99f, 100f
junctional nevi 39
modulated 33
postoperative care 91, 99f, 100f
pretreatment regimen 89
sebaceous hyperplasia 39
seborrheic keratoses 39
solar keratoses 39
treatment guidelines for 49
trichoepithelioma 39
Erbium:yttrium-scandium-galliumgarnet (YSGG) 105, 177, 178f
Erythroplasia of Queyrat/Bowens
disease 410, 411f
uorouracil in 411
imiquimod 411
PDT 411
pulsed CO2 Laser in 411
Eutectic mixture of local anesthetic
(EMLA) 534
absorption and distribution 534
adverse effects 536

allergic contact dermatitis 536
petechia 536
methemoglobinemia 537
usage guidelines 535
Excimer laser 423
Excimer laser indications 395
halo nevus 395
hypopigmented striae 395
nevus depigmentosus 395
postresurfacing leukoderma 395
Eye safety 496, 498
Eyelid laxity 286
F
Faces 311
Facial telangiectasia 241
Far infrared systems 11
Fibroblast growth factor 399
Fibrous papule of nose 381
Fitzpatrick skin type 261, 329
Fitzpatrick wrinkle classication
system 316
Flashlamp-pumped pulsed dye
lasers 237
Flavin 12
Fluence 32, 32f, 89, 255
in hair removal laser 255
Fluorescent lamps 9
Fluorescent pulse light 258
Folliculitis 367
Fractional ablative lasers 275
Fractional ablative radiotherapy 184
Fractional devices 488
Fractional laser 180t-182t, 366, 370, 418,
422, 522
complications of 478
in acne scars 204, 205t
boxcar scars 207, 207f
ice pick scars 205f, 206
rolling scars 204, 205f, 206f
in actinic keratoses 223
in Beckers nevus 226
in lichen amyloidosis 226
in melasma 224
in nevus of Ota 226
Index 547
in non-acne scars 220
in photodamage skin 217, 219f
in poikiloderma of civatte 227
in post-acne scarring 204
in post-inflammatory
hyperpigmentation 226
in rhytides 220
in striae 223
indications 193, 194t
minocycline pigmentation 226
Fractional photothermolysis 172, 366
collagen remodeling in 172
elastic tissue formation in 172
intraoperative 195, 230
intraoperative scanning hand piece
195, 196f, 230
intraoperative stamping hand piece
197, 230
patient selection 229
anxiety level 229
herpes simplex infection 229
isotretinoin use 194, 229
keloids 229
lidocaine allergy 229
pain tolerance 229
postinflammatory
postoperative management 198, 231
preoperative steps 194, 229
anesthesia 230
antiviral prophylaxis 194, 230
baseline photograph 230
sunscreens 229
rapid healing in 174, 174f
Fractional thulium laser 185
Freckles 108t, 113, 134, 436
Frequency-doubled QS Nd:YAG
lasers 133
Fresnel reflectance 3
G
Gas lasers 5
Gate theory by Melzack and Wall 301
Glomus 407
pulsed dye laser in 407
Grafting 236
Granuloma annulare 386

PDL in 386
Granuloma faciale 387
argon laser in 387
Green yellow (GY) wavelengths 10
H
Hailey-Hailey disease 286, 387
carbon dioxide laser in 387
Er:YAG 2,940-nm laser in 387
Hair growth devices 489
Hair reduction lasers 417
alexandrite-755 nm 417
diode-810 nm 417
IPL-4001200 nm 417
IPL-5901,200 nm 418
LP Nd:YAG-1064 nm 417
QS alexandrite laser-755 nm 418
QS frequency doubled Nd:YAG
laser-532 nm 418
QS Nd:YAG laser-1,064 nm 418
QS ruby laser-694 nm 418
Hair removal 514
Hair removal devices 258, 259, 489
475 to 1,200 nm IPL Silkn device 259
810-nm diode Tria laser 259
diode combined with RF 258
intense pulsed light (IPL) system
(5151,200 nm) 258
long-pulsed
alexandrite laser (755 nm) 258
Nd:YAG laser (1,064 nm) 258
ruby laser 258
semiconductor diode laser
(800810 nm) 258
optical light energy combined with
RF 258
Hair removal laser 252272, 423, 438
cooling mechanism in 256
chill tip cooling 256
cryogen sprays 256
forced refrigerated air 256
ice packs 256
Hair types 253
terminal 253
vellus 253
Halogen lamps 11

Hemangioma 246, 279
KTP 248
long-pulse PDL in 248
Nd:YAG 1,064 laser in 248
Hemostasis 32, 64
Hidrocystomas 71
High intensity focused ultrasound
(HIFU) 346
1440 nm lasers 350
635 nm laser 350
advantages 354
diode lasers 349
LipoSonixTM 348
preoperative workup 352
procedure 351
smoothshapes 350
techniques 352
ultrashape 346
with Nd:YAG laser 349
Highly pigment selective lasers 105
Hirsutism 254
Histological depth 476
Home use devices 258, 488
Horis macules see ABNOM
HPV infection 80
Human papilloma virus 77
Hybrid monopolar and bipolar
radiofrequency 313
Hydroquinone 109
Hyperemia 222
Hyperthermia 14
Hypertrichosis 254
Hypertrophic scars 361
I
Ice pick scars 206
IFUS
in body contouring 331
in tissue laxity management 330
Infantile hemangioma 239
bleeding in 240
deep 240
infection in 240
mixed 240
superficial 240
ulceration in 240
Infraorbital hyperpigmentation 108, 157

Infrared laser 277, 283
1,064 nm Nd:YAG 283
1,450 nm diode acne 284
1,450 nm mid-infrared diode
laser 283
fine lines 283
in acne scars on face 283
in acne vulgaris 283
in wrinkles 283
1,540 nm erbium: glass(NAFR) 284
in melasma 285
in perioral and periorbital rhytids
285
in periorbital rhytides 285
in pigmented lesions 285
in scarring 285
in skin resurfacing 285
1,540 nm Erbium:glass 283
infrared laser-1,320 nm Nd:YAG 284
in acne scarring 284
in photodamage 284
infrared laser-1,550 nm erbium-doped
fiber 285
Infrared light devices 314
Infrared radiation 497
Infrared wavelength lasers 380
Ingrowing toe nail 81
Intense focused ultrasound 185, 319
Intense pulsed light 275, 280, 367, 483
devices 241, 278
in pigmentation 280
in vascular lesions 280
Interrupted radiation 7
Invisible light lasers 277
Isotretinoin 194
K
Keloids 361, 362, 436
Kirby Desai scale 119
Kirby Desai score 116, 161
Klippel-Trenaunay syndrome 239
Koenen tumors 381
Kojic acid 152
KTP lasers 275, 279
Index 549
L
Labial melanotic macules 133
Labile psoriasis 88
Large lipomas 487
Laser and melanocyte grafting 396
Laser beam profiles 8
Gaussian or bell-shaped 8, 9f
top hat beam 8f
Laser clinic 416
private setup 416
public funded 421
FDA 510(K) clearances 426
laser procurement 424
regulatory approval 425
Laser complications 455, 456
crusting and vesiculation 458
dyspigmentation/post-inflammatory
erythema and edema 457
fractional lasers 463
post-inflammatory
hair removal lasers 464
burns 465
hypertrichosis 464
leukotrichia 464
pigmentary alterations 467
pigmented lesions laser 466
reticulate erythema 465
tissue splatter and pinpoint
bleeding 466
urticarial-like plaques 465
hypopigmentation 461
lasers for pigmented lesions
leukotrichia 468
tissue splatter 466
pigmentary alterations 467
pinpoint bleeding 466
pain 456
purpura 459
scarring 462
vascular lesions 468
reticulated purpura 468
Laser for acute wounds 408
Laser for chronic wounds 409
Laser for inducing leukoderma 396
monobenzylether of hydroquinone
396
Q-switched alexandrite laser 397

Q-switched ruby 397
Laser hair reduction
consent form in 260
contraindications of 257
herpes labialis 257
staphylococcal infection 257
superficial cuts and injuries 258
systemic lupus erythematosus 257
drugs used in 261
eflornithine role 268, 271
for gray hair 269
hair color in 261
indications of 257, 257f
marking of area in 262
pseudofolliculitis in 269
results of 260
long-term efcacy 260
short-term efcacy 260
test patch in 262
topical anesthetics in 262
Laser lipolysis 341, 349, 423
Laser penetration depth of 22
Laser safety standards 499
Laser surgery complications 439
postinflammatory hyperpigmentation
439
Laser therapy for scars 363
Laser tissue interaction 13
Law of Snellius 12
Leal laxity classication system 316
Leds 275, 278
590 nm nonthermal full-face leds
282
633 nm leds therapy 281
combination therapy with 830 nm and
633 nm 281
Lentigines 108t, 276
Lesional darkening 161
Lesions geometry 21
Less pigment selective laser 105
Levofloxacin 42
LHR
dark skin types 270
electrical safety 268
eye protection in 263, 268
fire protection in 268
in pregnant women 271

post-procedure care 263
side effects 265
crusting 265
deep burn 266
mild burning 265
paradoxical hair stimulation 266,
267f
perifollicular erythema 265
permanent scarring 265
persistent erythema 265
superficial burns 266
thermal burns 265
transient erythema post-session
265
vesiculation 265
Lichen sclerosus 387
carbon dioxide in 388
clotebatosol propionate in 387
Lidocaine 528
absorption and distribution 528, 532
adverse effects 530, 533
allergic reactions 531
clinical use in dermatology 533
CNS toxicity 530
CVS toxicity 531
mechanism of action 528, 532
usage guidelines 533
Light-based devices and laser-assisted
lipolysis 349
Light-emitting diodes (LED) 281
Linear porokeratosis 286
Long pulse 1,064 nm Nd:YAG 294
Low power 410 nm led 9
Low-level laser therapy (LLLT) 399, 400
alopecia 401t
hair laser 399
HairMax LaserComb 399
in alopecia 399
laser hair brush and clinical unit 399
photobiostimulation 400
LPG systems 343
Lumenis
SuperPulse CO2 179f
UltraPulse CO2 179f
Lupus erythematosus 388
PDL 388
Lupus pernio 390

532-nm frequency-doubled Nd:YAG
laser 390
carbon dioxide laser 390
M
Macrowound 186
Malpractice claims 448
Matted telangiectasias 227
Medical negligence 445
Medicolegal aspects of lasers in
dermatological practice 441
Melanin 12, 17, 101, 102f, 254, 269, 277
invisible light lasers 277
Melanized keratinocytes 105
Melanocytes 105
Melanocytic nevus 436
Melasma 108, 142, 225
Er:YAG 144
pigment specific 142
Microfocused ultrasound 322, 327, 333
Microsecond lasers 6
Microthermal zone (MTZ) 172, 174, 175
190-193
Mid-infrared lasers 11
Minimally ablative lasers 275
Minocycline pigmentation 158
Modulated Er:YAG 67
Moles 108
Molluscum contagiosum 384
adapalene in 384
cantharidin in 384
cryosurgery in 384
curettage in 384
ashlamp-pumped pulsed dye
laser 384
uorouracil 384
salicylic acid in 384
topical imiquimod 384
tretinoin in 384
Monopolar RF 278
Monotherapy 146t
Mycosis fungoides 413
Myxoid cysts 71
Index 551
N
NAFR (1,550 nm Erbium-doped fiber
laser) 366
Narrowband UVB 391, 394
Nd:YAG laser 13, 16, 17, 20, 22, 138, 279
1,064 nm 10, 279
1320 nm 175
1410 nm 175
1440 nm 175
Necrobiosis lipoidica 389
PDL 389
photodynamic therapy 389
Neodymium:yttrium-aluminum garnet
138, 237, 383, 532
Neurofibromas 71, 72, 381
Neurotoxins 220
Nevi, epidermal and dermal 67
Nevocellular nevus 106
Nevus comedonicus 68
Nevus of Ota 109, 152
combination of QS Nd:YAG-1 in 153
fractional laser in 153
laser result in 153, 154t
Qsw lasers in 152
scanned CO2 with Qsw laser in 152
Nevus Spilus 108, 109, 133
Nodular amyloidosis 389
PDL 389
Nominal hazard zone 493, 499
Nonablative fractional
laser and fractional ablative lasers
comparison 478
rejuvenation (NAFR) 275
resurfacing (NAFR) 175, 175f
Nonablative lasers 369
1,064 nm Q-switched Nd:YAG laser
369
1,320 Nd:YAG laser 369
1,450 nm diode laser 369
1,540-nm erbium-doped phosphate
glass laser 369
585 nm PDL and intense pulse light
system 369
Non-invasive body contouring 342
contraindications 342
treatment devices 342

radiofrequency energy devices 343
suction/massage devices 342
Nonsurgical sculpting 358, 484
issues and controversies 358
Nova-pulse 28
Novel wavelengths 479, 486
Novus actus interveniens 447
Nuclear acids 12
O
Onychomycosis 403, 405t
Operational modes 7
Optical spectrum 4
Oral retinoid therapy 41
Organic dye 237
Oxyhemoglobin 237, 254, 383, 388
in vascular lesion 237
P
Pagets disease 412
pulsed CO2 laser in 412
Pain free lasers 271
Paint-brush motion 177
Parapsoriasis 413
Patient information sheet 514, 521
Pattern alopecia 227
PDL 364, 374
acne scars 364
edema of 366
facial scars resulting from cutaneous
surgery 364
in hypertrophic scars and keloids 364
purpura 366
skin 366
sternotomy scars 364
Pearly penile papules 72, 227
PEODN 68, 68f
Permanent hair reduction 252
FDAs definition 252
Photoaged skin 286
Photodamaged skin 283
classification of 276t
laser use 289

Photodisruption 16
Photodynamic therapy (PDT) 271, 380
P. acnes 380
photodestruction of 380
photodestruction of sebaceous glands
in 380
Photothermal destruction 254
Photothermal reactions 14
Photothermolysis 126
Pigment nonselective lasers 105
Pigment selective laser 103, 103f, 105,
106, 116, 137
in selective disorders 108t
Pigmented lesions laser 472
Pigmented lesions/tattoos
dose/method 110
end points 161
intraoperative steps 161
patient information sheet 517
postoperative steps 161
preoperative steps 160
anesthesia 160
baseline photograph 160
biopsy 160
eye safety 161
pretreatment preparation 109
steps of therapy 109, 110t
subsequent sittings 112
treatment prerequisites 109
Pinpoint bleeding 90, 91
Plantar warts 31
Plasma skin regeneration 38
Pneumatic skin flattening (PSF) 271
Pockel cell 8
Poikiloderma of civatte 241
Polycystic ovarian disease (PCOD) 261,
269
Popsicle panniculitis 355
Porphyrin 12
Portrait plasma skin regeneration 279
Portrait PSR 285
contraindications 286
dose 286
Port-wine stains 236, 239, 244, 279, 388,
483
argon laser in 245
PDL 244
PDL adverse events in

discoloration 245
epidermal crusting 245
hypertrophic scarring 245
keloid formation 245
purpura 245
post-capillary venules involvement
239
segmental 239
Post-inflammatory hyperpigmentation
151
vascular lasers 151
Post-inflammatory hypopigmentation
227
Post-traumatic 220
Potassium titanyl phosphate (KTP) 241
Power density 6
Practical laser therapy
indications 193, 194t
intraoperative procedure 195
method of use 195
autofill scan mode 196
dose 197
interlaced 196
normal mode 196
scanning mode 195
sittings 198
post-operative instructions 198
antibiotic medication 199
anti-inflammatory medication 199
preoperative evaluation prophylactic
antibiotic 194
antiviral 194
side effects 199
bronzing 199
edema 199
flaking 199
postoperative discomfort 199
sunburn like erythema 199
sunburn sensation 199
Prescars 362, 372
in 585 nm PDL system 372
in Er:YAG laser 372
Prilocaine 532
Principles of laser therapy for scars 371
Procollagen production 278
Index 553
Propionibacterium acnes 379
Proteus syndrome 239
Psoralen plus UVA 391
Psoriasis 390
PUVA/SOL 390
ultraviolet B phototherapy 391
Pulse carbon dioxide 432
thermal relaxation time 432
Pulse duration 255
in fractional laser treatment 187
Pulsed CO2 lasers 21, 39
in zoons balanitis 39
used in dermal disorders 39
Pulsed CO2, treatment guidelines for 49
Pulsed dye laser (PDL) 138, 241, 279,
367
Pulsed dye, Q-switched (Qsw) 138
Pulsed Er:YAG laser 66
Pulsed MIR lasers 16
Q
QS 1064 nm Nd:YAG laser 156
comparison of 138
QS 532-nm Nd:YAG laser, combination
of 156
QS ruby lasers 133
Qsw lasers 8, 20, 101,157
ablative lasers 157
fractional lasers YSGG 2,790 nm 157
Q-switched alexandrite laser 105, 133
157
Nd:YAG comparison 138
Q-switched lasers
Q-switched Nd:YAG laser 105, 158
Q-switched neodymium 105
Q-switched ruby laser 105, 383
R
R20R technique 125
Radiofrequency 295297
bipolar 295
combination devices 295
polaris WR systems 295
current-based devices 319
monopolar RF
collagen contraction 298
immediate skin tightening in 298
multipolar 295
patient information sheet 524
principles of RF 295
unipolar RF 295
Recalcitrant disseminated superficial
actinic porokeratosis 227
Recalcitrant tattoos, lasers and
modifications used 128
Red and near IR wavelengths 10
Refirme ST system 312
Repeat mode 55
Residual thermal damage (RTD) 34, 56
lentigos 56
photodamage 56
Resurfacing mode 52
Resurfacing techniques
circular 43
end points 44
paintbrush 44
single spot 44
types of 43
ResurFx module 479
Retinol 12
RF monopolar devices 300
bipolar RF 309
disadvantage 311
exilis elite device 309
multiple variations of 309
thermage 300
abdomen 305
anesthesia 305
back of hands 305
coupling uid 305
CPT (comfort pulse technology)
302
exclusion criterion 304
hooding of eyelids 305
improve skin tone 308
improved jawline contouring 306
in acne 308
in cellulite 308
in periorbital skin laxity 300
in rhytides 300
jawline 305
lifting of eyelids 307

marking square grids 303
relative contradiction 305
side effects 306
smoothing 308
softening of wrinkles 307
suitable candidates 304
tens therapy 300
Thermacool NXT device 300
thighs 305
tightening of skin 308
Rhytides 91, 286
Ribonucleic acid (RNA) 12
Rolling technique 189, 190
Rosacea 240
erythematotelangiectatic 240
ocular 240
papulopustular 240
phymatous 240
staging 240
telangiectasias 388
PDL 388
S
Sarcoidosis 389
Scar sarcoidosis 390
Q-switched ruby laser in 390
Scars 40, 361
Sebaceous hyperplasia 71, 74
Seborrheic keratoses 73, 97f, 134, 286,
383
Er:YAG 134
pulsed CO2 lasers 134
Selective cryolipolysis 355, 356
Selective photothermolysis 17, 26, 254
and laser assisted hair removal 20
fractional photothermolysis
difference 174, 174t
of cutaneous blood vessels 20
of pigmented lesions 20
of tattoos 19
theory 236
Selectine potothermostimulation 487
Sharplan SilkLaser 28
Skin cooling 256
Skin tightening devices 294t
Soe syndrome 288

Solid-state lasers 5
Spider hemangiomas 407
high-powered 532-nm device 407
PDL 407
Spot 113
diameter 21
laser resurfacing 63
size 35, 89, 124, 256
in Qsw laser 125f
Stamped scanning technology 177
Stamping technique 189, 190f
Steatocystomas 74
Stress confinement 15
Stretch marks 361
Striae distensae 373, 481
1,064 nm Nd:YAG laser 374
308-nm excimer laser 374
flash-pumped 585 nm pulse dye laser
374
intense pulsed light 374
nonablative 1,450 nm diode laser 374
nonablative fractional CO2 resurfacing
374
radiofrequency device 374
Sturge-Weber syndrome 239
Subablative pulses 35
multiple 35
Subsurface lasers 275, 423
Superficial dermal plexus 35
Superficial skin lesions 286
Supertumescence 358
Surgical scars 220
Syringocystadenoma papilliferum 71
Syringomas 35, 71, 73, 98f
System, of Richard Glogau 276
T
T. mentagrophytes 404
T. rubrum 403
Tattoo 115, 436, 472
Tattoo dependent factors
age 122
amateur 120
color 121
ideal interval 125
Index 555
ideal technique 126
location 122
non-responsive tattoo ink 124
paradoxical ink darkening 123
professional 120
pulse duration 126
scar/granuloma 123
sessions 126
skin type 123
undesired pigmentary alteration 124
Tattoo pigments 115
absorption spectrum 118f
laser induced resolution 118, 119
laser used for removal 118t, 122t
Tattoo removal 119
paradoxical ink darkening 123
patient-dependent factors 119, 120,
123
scar/granuloma 123
skin type 123
tattoo-dependent factors 120
Tattoo types 117t
traumatic 117t
amateur 117t
cosmetic 117t
iatrogenic 117t
medicinal 117t
professional 117t
Telangiectasia 249, 276, 407
apider 249
arborizing 249
papular 249
PDL in 249, 407
simple or linear 249
Telogen efuvium 399
Thermal coagulation points (TCP) 322
Thermal connement 15
Thermal damage 15, 20, 28, 30, 35
Thermal diffusion 15
in radiofrequency 299
monopolar rf type I collagen 299
Thermal injury 32
Thermal necrosis 32
Thermal relaxation time (TRT) 17, 18, 36
Thermal zone 322
Tissue ablation 15
Titanium sapphire laser 16
TriactiveTM 343
Trichoepithelioma 381
Trichoscan images 262
Tumescent liposuction using suction
cannulas 337
Typical complications of laser 442t
U
Ulthera 322, 325
UltraPulse CO2 and superPulse CO2
comparison 478
UltraPulse or Er:YAG laser 76
Ultrashort laser pulses 8
Ultrasound-assisted liposuction (UAL)
320
Ultrasound devices 315
Unipolar RF devices 345
tripolar radiofrequency 346
Freezetm 346
Titefxtm 346
Tripollartm 346
UV laser 9, 16
in inflammatory skin diseases 9
in vitiligo 9
UV light 497
V
Vaporization mode 54
Varicose veins 241
Vascular laser therapy
intraoperative 242
patient selection 242
postoperative 243
blister and/or crust formation 243
topical steroid-antibiotic cream
usage 243
preoperative 242
lignocaine 242
prilocaine 242
Vascular laser 278, 422, 483
intense pulsed light (IPL) 238
port-wine stain 239
absence of perivascular nervous
tissue 239
diffuse 239
extensive 239

Venous lakes 241, 408
755-nm alexandrite lasers 408
combined 595-nm/1,064-nm
multiplex device 408
long-pulse Nd:YAG lasers 408
PDLS 408
Vicarious liability 443
Violet IPL emissions 9
Viral diseases 41
Viral disorders 383
CO2 laser light in 383
FPDL 383
lasers used 383
Viral papillomata 286
Viral warts 384
FPDL treatment
blistering 384
post-lesional hyperpigmentation
384
scarring 384
Visible light lasers 277
Vitiligo 88, 393

308-nm excimer laser in 394
632.8-nm helium-neon laser in 394
Vulvar lichen sclerosus 388
W
Water, infrared lasers 277
Wavelength 255
in fractional laser treatment 187
Wound healing 408
Wrinkles 41
X
Xanthelasma 71, 75, 77f
Z
Zoons balanitis 409

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LASERS

Kabir Sardana MD DNB MNAMS

Vijay K Garg MD MNAMS

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Jaypee Brothers Medical Publishers (P) Ltd

Jaypee-Highlights Medical Publishers Inc

Jaypee Brothers Medical Publishers (P) Ltd

My family and friends

viii Lasers in Dermatological Practice

Medical Director and

Professor-Emeritus, Dr MGR Medical University

xvi Lasers in Dermatological Practice

Real knowledge is to know the extent of ones ignorance

1. Basics of Laser-Tissue Interactions

Section 2: Advanced Laser Interventions

Section 3: Practical Aspects and Advances

Miscellaneous Laser Responsive Disorders

xviii Lasers in Dermatological Practice

Laser Safety/Eye Care

Laser and Medical Devices (Index)

4 Lasers in Dermatological Practice

Fig. 1.1: Absorption spectrum of various lasers in

environment due to multiple scattering in the epidermis and dermis, as well

Basics of Laser-Tissue Interactions 5

of penetration increases with wavelength. Above 1300 nm, penetration

Types of Light Devices

Light Device Terminology

Fig. 1.2: Various output modes of a conventional laser

6 Lasers in Dermatological Practice

Power density W/A (irradiance)

Peak power P max (W)

For pulsed lasers

Energy E per pulse (J)

For pulsed lasers

Pulse duration t [fs (10 )

For pulsed lasers

Energy density E/A (radiant

For pulsed lasers

Cw: continuous wave, fs: femtosecond, ms: millisecond

Energy: Measured in Joules (J).

Basics of Laser-Tissue Interactions 7

Fig. 1.3: A figurative depiction of the energy and duration of

8 Lasers in Dermatological Practice

Beam Profiles: Top Hat versus Gaussian

Basics of Laser-Tissue Interactions 9

many lasers, this profile represents the fundamental optimized mode of

Wavelength Ranges and Clinical Application

Fig. 1.5: Optical penetration depth of common lasers used in dermatology

10 Lasers in Dermatological Practice

3. Green Yellow (GY): These wavelengths are highly absorbed by

Basics of Laser-Tissue Interactions 11

nodular port wine stains or hemangiomas, can be safely targeted. On the

12 Lasers in Dermatological Practice

according to the angle of incidence. Photons penetrating the surface initially

Basics of Laser-Tissue Interactions 13

14 Lasers in Dermatological Practice

Fig. 1.7: A figurative depiction of the plot of laser tissue interaction

Basics of Laser-Tissue Interactions 15

Thermal diffusion is responsible for heat ow into the tissue. If the

1. Basics of Laser-Tissue Interactions

Miscellaneous Laser Responsive Disorders

Laser Safety/Eye Care

Laser and Medical Devices (Index)

1. Derma 20 (ESC Medical Systems