LASERS, General Principles and Physics

http://tajmeel.ta.ohost.de Dr. Mohamed El Rouby . Lecturer of Plastic Surgery +20101556023 or +20126531265 or elroubyegypt@gmail.com LASER = light amplification by stimulated emission of radiation. A LASER-equipped device can generate a high-intensity light that is monochromatic, unidirectional, and parallel. HISTORY
The ruby LASER was the first medical LASER when it was used in 1963 to coagulate retinal lesions. Other substances were ultimately found that could serve as the active medium of a LASER device. Many substrates, especially rare earth elements such as erbium (Er), gadolinium (Gd), holmium (Ho), praseodymium (Pr), thulium (Tm), uranium (Ur), and ytterbium (Yb), have been used successfully. The erbium:yttrium-aluminum-garnet (Er:YAG) Its unusual name derives from the Swedish town of Ytterby, which is the site of a mine where the silvery rare-earth elements erbium and yttrium were discovered. In 1961, a LASER generated from crystals of yttrium-aluminum-garnet treated with 1-3% neodymium (Nd:YAG) was developed. This LASER emitted energy in the near infrared (IR) spectrum at a wavelength of 1060 nm. Researchers found its high-penetration emission to be useful for vaporizing tissues and thermally coagulating large blood vessels (<3 mm). Today, the Nd:YAG LASER is mainly used to ablate tattoos and tumors of the genitourinary and gastrointestinal tracts, and hair removal. The first gas LASER, which was also developed in 1961, used a mixture of helium and neon. Though its beam was not powerful enough to trigger a thermal reaction, its red color allowed it to be used as an aiming beam for invisible LASERs e.g. CO2. Currently, it is used to relieve pain and wound healing. In 1962, the argon LASER was developed. This LASER emitted energy in the blue-green portion of the electromagnetic spectrum. Energy with wavelengths in this part of the spectrum is more readily absorbed by 2 naturally occurring chromophores (absorbing pigments) in the human bodymelanin and hemoglobinthan by the surrounding tissue. Today, the argon LASER is used to photocoagulate (ie, thermally obliterate without vaporization) blood vessels in the treatment of diabetic retinopathy and portwine stains. In 1964, Patel at Bell Laboratories developed the CO2 LASER. It emitted spectral energy in the far IR portion of the electromagnetic spectrum at 10,600 nm. At this wavelength, energy is heavily absorbed by water, which is the primary constituent and chromophore of cells in living tissue. Thus, the energy generated by this LASER can be used for cutting or volume ablation by means of tissue vaporization. This unique characteristic makes the CO2 LASER the most widely used medical LASER today.

PHYSICS

Atoms at their resting energy state, or ground state (E0), Spontaneous Emission Of Radiation: E0 + energy higher energy state (E*) [absorb electrical, optical, or thermal energy]. E* (unstable and spontaneously) E0 + absorbed energy as light or photons. Stimulated Emission: E* + energy E0 + an amount of energy twice the original. i.e. photon + E0 E* & if 2nd photon + E* E0 + 2 photons of the same frequency.

 This emission occurs in phase (coherence) with and in the same direction as the first bombarding photon. The 2 emitted photons may then each strike other excited atoms, further stimulating emission of photons E*> E0 system inversion . This chain reaction rapidly produces a powerful eruption of a coherent beam of radiation (LASER).

BASIC COMPONENTS The basic LASER device consists of 3 components: (1) an active medium, or lasing medium; (2) an optical cavity, or resonator; (3) an energizing source, or pump.

The active medium may be a solid, liquid, or gas. Different active media emit different energies or wavelengths of light. The resonator contains an active medium. At each end of the resonator, parallel reflectors or mirrors are placed facing each other. The front of the output mirror is designed to be partially reflective. It reflects only a portion of the light impinging on it, allowing some portion of the total energy or light to escape. The rear mirror is a total reflector that reflects 100% of the energy impinging on it. The pump source provides the energy (thermal, electric, or optical [eg, a flash lamp]) for absorption by the active medium.

 Mechanism: sufficient energy pump the active medium population inversion spontaneous emission of photons Some of these photons are reflected back and forth between the 2 mirrors (others are dissipated as heat) and then collide with atoms in the excited state stimulate the emission of radiation. At the front output mirror, a portion of the energy is permitted to escape. This energy is in the form of an intense beam of monochromatic (same wavelength), collimated (parallel, nondiverging), and coherent (same direction).

LASER PROPERTIES Light measurements used routinely in laser applications include:. Energy is proportional to the number of photons and is measured in joules (J). Power the rate of delivery of the energy, is measured in watts (W) where: 1 W = 1 J/S Irradiance = power per unit area and is measured in W/cm2. Fluence = the energy delivered per unit area and is measured in J/cm2. A. Power density (Intensity = irradiance) The LASER beam exits the resonator, is often too large diameter and diffuse.Therefore, the beam is passed through a focusing lens diameter its intensity and energy. Intensity = its power density (Pd) or irradiance (E), the energy delivered per unit area of incident tissue. It is measured in terms of watt of LASER per diameter of the beam. That is, Pd varies inversely with the square of the diameter of the LASER beam, as follows: o Pd = (100W)/d2, where W is the LASER power in watts, and d is the diameter of the LASER beam in centimeters (ie, 100W/cm2).
i.e. For a given wattage, a wide or unfocused beam has less penetration ability and is more useful for procedures such as skin resurfacing, vaporization of tissue, and coagulation of blood vessels. A focused beam penetrates to a greater depth and is more useful in procedures involving delicate cutting and volume ablation.

B. Fluence (Dose = Intensity x Duration of exposure) Prolonged exposures result in tissue destruction, and too short an exposure results in an inadequate effect. The dose, or fluence, is a measure of the total energy. Energy fluence (density) necessary to vaporize tissue is approximately 5 J/cm2 (ablation threshold). It is determined by multiplying Pd by the exposure time (t) and is expressed in terms of energy (joule) per unit area of incident tissue, as follows: o Fluence = Pdxt = J/A, where J is the energy in joules and A is the crosssectional area of beam in square centimeters. C. Wavelength The effect of light on skin depends on the wavelength of the light. Light in the UV region (100-400 nm), invisible, cause deleterious effects such as erythema, hyperpigmentation, and cutaneous carcinoma.

 Light energy in the visible spectrum (380-700 nm) is mostly innocuous, but it can be absorbed and cause thermal damage when it is delivered to the skin at a high intensity. Light in the near IR region of the spectrum (780-3000 nm), also invisible, causes skin and retinal defects. [In general, the effects of light in the mid-to-far IR region of the spectrum (3-1000 m) are limited to the superficial layers].

The degree of absorption and its thermal effect on skin vary with the amount and type of chromophores that are present in the recipient. Different chromophores have different absorption coefficients = a measure of the degree of absorption by the chromophores at a particular wavelength. Hemoglobin and melanin are natural endogenous chromophores. Tattoo ink is exogenous chromophore. Because the LASER is monochromatic and because it has a very narrow bandwidth, it permits selective targeting of chromophores in the tissue for treatment. This property is one of the underlying principles of selective photothermolysis (SP). Chromophore: is a chemical substance of the molecule that give it its color. Complementary Colors: Newton's hue circle completely requires that every spectral hue will have a single spectral opposite (or mixture of two opposite spectral hues) that can combine with it to create white light.

Newton stated the definition of complementary colors that is still used today: any two hues that, mixed in the right proportions, produce a "faint anonymous" neutral (pure white, gray or black) color. (i.e. yellow/blue and red/green) Light color mixing is different from color mixing in substances: three monochromatic lights (blue 460nm, green 530nm and red 650nm) How do we determine the exact complementary color for any color we choose? The simplest way is to determine quantities of the two opponent processes that determine the chosen color (redC1 + yellowC2)=(orange), then identify the color that is produced if we apply the same quantities to the opposing process hues (greenC1 + blueC2) = (greenish blue) .

 subtractive color mixing: A subtractive mixture absorbs all light wavelengths that each colorant absorbed by itself. There is one general rule we can rely on, however. When we materially mix paints, dyes or filters, we do not increase their light reflecting (transmitting) behavior but their light absorbing behavior. D. Selective photothermolysis In 1983, Anderson and Parrish described the theory of selective photothermolysis, SP is a method for localizing tissue damage to specific chromophore targets at the cellular level; therefore, it can be used to minimize undesired thermal damage to the surrounding tissue caused by thermal diffusion. The mentioned LASER parameters [power density, fluence, and wavelength] are the fundamental principles in the operation of medical LASERs in the concept known as SP. thermal relaxation time (TR) The rate of thermal diffusion of a given tissue = the time required for a given heated tissue to lose 50% of its heat through diffusion. It is measured in terms of the area affected and the thermal diffusivity (D) of the target tissue, as follows: TR = r2/4D, where r is the radius of target tissue. Therefore, if the duration of the LASER pulse is < TR of the target tissue thermal diffusion (and hence thermal damage). For example, water has a high absorption coefficient of 230 cm-1 at 10,600 nm, (the wavelength emission of a CO2 LASER), and a TR of 326 s: o if a CO2 LASER contacts the skin for < 326 s most of the radiation is absorbed by the water in the targeted skin almost no thermal diffusion. o if the duration of the LASER impingement on the tissue is > 326 s heat is transmitted to the surrounding nontargeted tissue undesirable thermal injury. Therefore, for proper SP to occur, the target tissue (chromophores) must possess greater optical absorption than the nontargeted surrounding tissue does, and the LASER of choice must have a pulse duration shorter than the TR of the target tissue. Because soft tissues in humans generally have a TR of < 1 ms, the LASER pulse must be extremely short and high-powered to be minimally destructive. E. MODES: CONTINUOUS WAVE, PULSED, AND Q SWITCHING The generated LASER beam, in general, can be delivered in 2 ways. The 2 types of LASERs are fundamentally different in design, light delivery, and operation. as a constant flow of energy (continuous-wave [CW] LASER as multiple discrete pulses (pulsed LASER). A CW LASER: continuously pumping energy into the active medium to achieve an equilibrium between the number of E* atoms and the number of photons emitted continuous LASER. The duration of a CW LASER pulse is approximately 0.25 s. With this duration and with relatively constant power delivery to tissues, significant thermal damage occurs. To minimize their destructive effects, CW LASERs have been modified to emit beams in a pulsatile fashion by adding electronically controlled, mechanically gated, timed

shutters to interrupt the output beam at preset intervals. (This system is not a true pulsed LASER per se because the LASER beam is physically chopped off to produce the pulse effect). Pulsed LASERs, in contrast, deliver high-energy beams in very short pulses in range of milliseconds without the use of a shutter. Emissions are produced when the pump is modulated to create discrete LASER pulses, which usually are broad and randomly shaped. Both types of can be further modified to produce even shorter pulses, usually in the range of 10-250 ns, by using a method referred to as Q switching. With this technique, a large population inversion builds before emission is stimulated. This population inversion is accomplished by using a mechanical opaque shutter or by inserting a high-speed, electrically sensitive, polarizable optical shutter known as a Pockel cell between the 2 mirrors of the LASER. Because this shutter effectively blocks the photons' path between the 2 mirrors and prevents resonation, stimulated emission does not occur. When the population inversion reaches its maximal level, the opaque mechanical shutter opens. When Pockel cells are used, an electrical pulse is applied to the cell that changes it from opaque to transparent, allowing the photons to reflect back and forth and subsequently generate an intense beam. Skin Optics Light that encounters the skin may be reflected, transmitted, scattered, or absorbed at each layer. Only absorbed light produces tissue effects. The stratum corneum reflects approximately 4% to 7% of visible light that encounters the skin. The dermis predominantly scatters light because of the collagen content. Within skin, certain structures called chromophores absorb light. Examples of endogenous chromophores are hemoglobin, oxyhemoglobin, and melanin. Exogenous compounds including tattoo ink may also act as chromophores. Absorbed light energy can produce thermal, mechanical, and chemical changes in skin. Thermal effects range from protein denaturation to vaporization and carbon formation. Chemical reactions occur when absorbed light leads to the production of chemically reactive excited state molecules, as in photodynamic therapy. Physical or mechanical photoacoustic changes, is caused by rapid thermal tissue expansion creating pressure waves fragment pigment particles in the dermis. Classification of LASERs The following criteria are used to classify lasers: 1. Wavelength. If the laser is designed to emit multiple wavelengths the classification is based on the most hazardous wavelength. 2. For continuous wave (CW) or repetitively pulsed lasers the average power output (Watts) and limiting exposure time inherent in the design are considered. 3. For pulsed lasers the total energy per pulse (Joule), pulse duration, pulse repetition frequency and emergent beam radiant exposure are considered. ANSI Classifications according to Hazardous effect: Class 1 under normal operating conditions, pose a hazard. Class 2 low-power visible lasers which, because of the normal human aversion response (i.e., blinking, eye movement, etc.), do not normally present a hazard, but may present some potential for hazard if viewed directly for extended periods of Class 3a a CAUTION label that normally would not injure the eye if viewed for only

momentary periods (within the aversion response period) with the unaided eye, but may present a greater hazard if viewed using collecting optics. Class 3b can produce a hazard it viewed directly. This includes intrabeam viewing of specular reflections. Class 4 produce a hazard not only from direct or specular reflections, but may also produce significant skin hazards as well as fire hazards.

CLINICAL AND DIAGNOSTIC APPLICATIONS

Laser Argon Long Pulsed dye KTP/double Ferq Nd:YAG Copper vapor FLPPD Long pulse Ruby, Q-switched Long pulse Q-switched Alexandrite Nd:YAG Q-switched YAG Er:YAG

Wavelength (nm) 488/514 510 532 578 585 595-600 694 694 755 1064 1064 2940

Color Blue Green Green Greenish-yellow Greenish-yellow Greenish-yellow Red Red Red Mid-IR Mid-IR IR

chromophore Melanin & haemoglobin Melanin Melanin & haemoglobin Melanin & haemoglobin Melanin & haemoglobin Melanin & haemoglobin Melanin Melanin Melanin & haemoglobin Melanin & haemoglobin Melanin & haemoglobin Protein (Scattered)

Application Vascular lesions Pigmented lesions Tattoo removal Pigmented lesions Vascular lesions Pigmented lesions Vascular lesions Vascular lesions Leg veins Pigmented lesions Tattoo removal Pigmented lesions Hair removal Pigmented lesions Tattoo removal Pigmented lesions Deep vascular Pigmented lesions Tattoo removal Skin resurfacing

CO2 10600 IR water Cut/coag/resurf Laser -- vascular lesions Telangiectasias: in order of preference/effectiveness Diode laser (variable-pulsed-width 532nm)-as effective as pulsed-dye without puerperal pulsed-dye laser (puerperal results) IPL Hemangiomas pulsed-dye laser (585nm wavelength) 2-10 treatments spaced 6-8 weeks apart Port-wine stains Pulsed-dye laser (585nm) 2-12 treatments spaced 6-8 weeks apart superficial lesions, red lesions, younger than 10, head and neck lesions respond better Laser superficial pigmented lesions Superficial lesions (generally shorter-wave-length systems) Freckles: Q-switched 532nm Nd:YAG laser recur frequently Caf-au-lait lesions: Q-switched Nd:YAG lasers difficult to treat, recur often Lentigos: Q-switched Nd:YAG lasers CO2, Erbium, KTP recurrence uncommon Peels, topicals Nevi: biopsy if suspicious Q-switched Nd:YAG 532, 694, 755nm lasers respond within 1-3 treatments Melasma: Q-switched Nd:YAG laser hormonal control bleaching agents sun avoidance tend to recur Rosacea: topicals (antibiotics, tretinoin) oral abx IPL KTP laser Laser -- deep pigmented lesions Deep lesions-deeper, therefore treated better with longer wavelength (goes deeper): can use ruby, alexandrite, and Nd:YAG blue nevi: 1064 nm Nd:YAG laser nevus of ota and ito: Q-switched 1064nm Nd:YAG laser multiple treatments recurrence is unusual Laser -- hair removal Wavelengths between 600 and 1000 nm most effective Ruby (Fitzpatrick skin types I-III) Diode 810nm can treat darker skinned patients (III-IV) 1064 nm YAG safest for skin types IV-VI. IPL appears equally as effective in skin types IV-VI IPL can be used in all skin types Different spectrum applicators Laser -- scar treatment
Scar Type Hypertrophic Keloid Striae Atrophic LASER Used 585-nm pulsed dye 585-nm pulsed dye 585-nm pulsed dye CO2 (10,600nm) Er:YAG (2940nm) Number of Treatments 2-4 2-6 1-2 1-2

Long-pulsed diode (1450nm) Long-pulsed Nd:YAG (1320nm)

Laser --Tattoo removal Q-switched Nd:YAG and alexandrite lasers are best used for removal of blue pigments

green tattoo

Nd:YAG laser works best for red, brown, and orange pigments, Q-switched ruby laser is used to remove tattoos with violet and purple pigments.
Because professional tattoos often extend deep within the dermis, multiple treatments are required. Laser -- skin resurfacing

CO2
Er:YAG Nd:YAG Coablation (radiofrequency) IPL Other Fields of practice Dentistry In endodontics, for dentin structure modification, cleaning and shaping of the root canal system, pulp diagnosis, and endodontic surgery. Nd:YAG, CO2, and semiconductor Diode LASERs have been used in soft tissue treatment of the oral cavity. In periodontics, the Er:YAG has potential for clinical application in hard tissue treatment due to its ability to cut or contour bone with minimal damage and fast healing. In orthodontics, in LASER surface scanning of craniofacial anomalies. Dermatology acne vulgaris, pseudofolliculitis barbae, and vascular and pigmented lesions. removal of unwanted hair (by the Nd:YAG), tattoos, and scars. Diagnostically, they are employed in the LASER-capture microdissection technique, which provides faster identification of infectious agents than standard diagnostic techniques based on the polymerase chain reaction (PCR). Oncology Photodynamic therapy involves the absorption of a photosensitizing agent (which interacts with visible light), retention of the agent in tumor tissue, and selective LASER irradiation of tumor tissues, which were previously sensitized by dyes. LASERs, particularly the LASER-capture microdissection technique, are an important part of proteomic technology for cancer diagnosis and the development of markers for early detection. In oncologic surgery, CO2 LASERs have been used for the surgical treatment of carcinomas of the oral cavity, pharynx, and larynx. LASER scanning cytometry LASERs have an application in the analysis of cells and their compartments. LSC is a new technique that has a significant advantage over other cytometric methods because of its use of the minimal sample volume and its ability to connect fluorescence and morphologic data. Possible applications of this technique include tissue biopsy, cytogenetic profiling, and determining ploidy and immunophenotype. LASER tissue welding LASER tissue welding is an alternative method for closure. The method is used especially in instances when stapling or suturing is difficult. The introduction of additional technology, such as protein solders, chromophore enhancement, and temperaturecontrolled feedback systems, has aided the recognition of this technique in clinical medicine. Low-level LASER therapy The low-intensity LASER, < 10-100 W, may be useful in cutaneous wound healing and pain relief. Pain research LASER pulses (from argon, CO2, Nd:YAG, and other LASERs) have been used in experimental and clinical studies to induce pain in both humans and animals. Activation of skin nociceptors with heat provides research data regarding the mechanisms of injury and sensitization, and therapeutic effects of various interventions.

Complications of Dermatologic LASER Surgery

LASER SAFETY COMPLICATIONS

 Eye : Acute exposure of the eye to lasers of certain wavelengths and power can cause corneal or retinal burns (or both). Chronic exposure to excessive levels may cause corneal or lenticular opacities (cataracts) or retinal injury. Skin : Acute exposure to high levels of optical radiation may cause skin burns; while carcinogenesis may occur for ultraviolet wavelengths (290-320 nm). Chemical : Some lasers require hazardous or toxic substances to operate (i.e., chemical dye, Excimer lasers). Electrical : Most lasers utilize high voltages that can be lethal. Fire : The solvents used in dye lasers are flammable. High voltage pulse or flash lamps may cause ignition. Flammable materials may be ignited by direct beams or specular reflections from high power continuous wave (CW) infrared lasers. PRIMARILY EPIDERMAL COMPLICATIONS Hyperpigmentation after almost any cutaneous LASER or IPL procedure, regardless of type. more common in darker skin types almost always a temporary effect that responds to topical bleaching therapy. relatively common after ablative (especially CO2 resurfacing), (3-4 months). with hair removal is related to seasonal variations, tan, and the skin type. Idiosyncratic hyperpigmentation may occur, so, patients should be warned of this risk. Hypopigmentation after pigment-specific LASER irradiation. (in tattoos or pigmented lesions treated with Q-switched ruby, alexandrite, and Nd:YAG LASERs). more commonly observed after multiple treatments more common in darker skin types With hair removal with the long-pulsed ruby and alexandrite LASERs. As with hyperpigmentation, temporary and occasionally persist (CO2 skin resurfacing). Postoperative blistering by several different LASER systems, but it is most commonly expected with Q-switched LASER irradiation for tattoo removal. by concomitant use of tissue cooling (through a contact chill tip or cryogen spray). Postoperative crusting by LASER-induced epidermal damage common with all Q-switched LASERs used for tattoo removal. In about 10% of patients, long-pulsed ruby and alexandrite LASERs may cause crusting when used for hair removal. Milia and acne Small white collection of keratin. commonly are observed 2-4 weeks after CO2 LASER resurfacing and partially are related to the use of occlusive ointments. by application of topical tretinoin or glycolic acid. PRIMARILY DERMAL COMPLICATIONS Purpura Purpura (or bruising) is often in patients after vascular-specific reatment (particularly with the 585-nm pulsed dye LASER). Purpura is a transient phenomenon that usually lasts 7-14 days. Its incidence has been with the recent development of pulsed dye LASERs with longer pulse durations, which permit slower heating of cutaneous vessels. Scarring relatively common with continuous-wave LASERs.

 Whether atrophic or hypertrophic, is always due to excess damage to the dermis. may arise from direct LASER-induced thermal damage or from complications such as postoperative infection. low with pigment-specific LASERs, nonCW vascular LASERs, nonablative LASER systems, and pulsed hair-removal LASER systems. Common with ablative resurfacing (both CO2 and Er:YAG). OTHER COMPLICATIONS
123 Delayed wound healing Wound infection Darkening of flesh-colored cosmetic tattoos ferric oxide to ferrous oxide 4- Allergic reactions after treatment of tattoos 5- Postoperative erythema 6- Contact dermatitis to topical PO medications

Facial Analysis for Skin Resurfacing

INTRODUCTION aesthetic results that are satisfactory to both the patient and the surgeon by comprehensive knowledge of: o LASER systems, o details and treatment parameters o appropriate patient selection o preoperative and postoperative care o application of new technologies. Before any intervention, a thorough facial analysis must be undertaken in order to design an appropriate treatment plan. PREOPERATIVE HISTORY a detailed medical and dermatological history with emphasis on wound healing and scar formation is essential. family history of abnormal wound healing, skin disorders, and ethnic background can facilitate an optimal outcome. If the patient has a history of collagen vascular diseases (eg, lupus, scleroderma, keloid formation) or immunologic abnormalities such as vitiligo, LASER treatment may need to be avoided because these conditions can cause problems with healing and can be relative contraindications to LASER resurfacing. ISOTRETINOIN AND RADIATION Ascertaining if the patient has used isotretinoin (Accutane) within 1 year before Er:YAG or CO2 LASER resurfacing is important. Some authors recommend discontinuation of isotretinoin for a minimum of 6 months Others recommend waiting at least 1 year or longer. The epithelial cells of the adnexal structures are a regenerative source for the reepithelialization of LASERed skin. Isotretinoin and radiation exposure destroy these adnexal structures. FITZPATRICK SKIN TYPE CLASSIFICATION Evaluation of facial skin pigmentation before LASER resurfacing is paramount to successful results.

 Pigment can be inherited ethnically or acquired as in melasma or Addison disease. A higher degree of preablative pigmentation increases the risk of hyperpigmentation and hypopigmentation after LASER resurfacing. Hormonal changes during pregnancy can vary the amount of pigmentation, and performing resurfacing in women who are pregnant is contraindicated. Fitzpatrick skin type classification.denotes 6 different skin types, skin color, and reaction to sun exposure. Type I (very white or freckled) - Always burn Type II (white) - Usually burn Type III (white to olive) - Sometimes burn Type IV (brown) - Rarely burn Type V (dark brown) - Very rarely burn Type VI (black) - Never burn

The higher the type and the degree of pigmentation, the greater the risk of postinflammatory hyperpigmentation.
However, persons who have minimal pigmentation can develop postoperative erythema

Obagi skin classification: This classification is probably the most comprehensive skin classification system. It analyzes skin using the following criteria (CTFFO): o Skin color - Original (light white, dark black, dark Asian) or deviated (brunette, white, light black, medium black, light Asian, medium Asian, complex skin); CO2 LASER resurfacing not recommended for any skin color other than light white, white, or brunette o Skin thickness - Thick, thin, medium (excessively thick or thin skin is a relative contraindication to this procedure) o Skin firmness - Firm versus lax o Skin fragility - Tough versus fragile o Skin oiliness - Oily, normal, dry

TYPES OF RHYTIDES Differentiation between static and dynamic wrinkles and the degree of rhytidosis must be ascertained and documented before LASER resurfacing. Certain aesthetic scenarios require a combination of LASER ablation and more invasive and traditional rejuvenative techniques to achieve adequate rhytide reduction. Face or midfacial lifting, forehead or brow elevation, and blepharoplasty may be coupled with resurfacing and tailored to the patient's needs. This combination of modalities may be performed together or better in stages (2-3 months). Dynamic Rhytides which exacerbated by active facial muscle contraction are more impervious to LASER resurfacing than static lines. Crow's feet and lateral smile lines around the eyes are deepened with smiling and can be treated with some success by reduction in wrinkle depth. Botulinum toxin treatment before resurfacing can lessen the mimetic-induced lines and provide a more pleasing aesthetic outcome. CLASSIFICATION OF RHYTIDOSIS Glogau developed the traditional rhytide/photoaging classification scheme that is used most often today:

Mild (age 28-35 years) - Little wrinkles, no keratosis, requires little or no makeup. Moderate (age 35-50 years) - Early wrinkling, sallow complexion with early actinic keratosis, requires little makeup

Advanced (age 50-60 years) - Persistent wrinkling, discoloration of the skin with telangiectasias and actinic keratosis, always wears makeup Severe (age 65-70 years) - Severe wrinkling, photoaging, gravitational and dynamic forces affecting skin, actinic keratosis + cancer, wears makeup with poor coverage Class I - Fine wrinkles Class II - Fine-to-moderately deep wrinkles and moderate number of wrinkle lines Class III - Fine-to-deep wrinkles, numerous wrinkle lines, and redundant folds possibly present

Fitzpatrick reported an alternative classification:

Fitzpatrick also correlated these classes to a scoring system and degree of elastosis: Class I = (score 1-3) Mild elastosis Class II = (score 4-6) Moderate elastosis Class III = (score 7-9) Severe elastosis Mild elastosis = fine textural changes with minimal skin lines. Moderate elastosis = a yellow discoloration of individual papules (papular elastosis). Severe elastosis = marked confluent elastosis with thickened, multipapular, and yellowed skin.

Skin Resurfacing: LASER Surgery

Pathophysiology: aging process, skin quality deteriorates: o Intrinsic aging (Chronological aging) from the genetically determined, natural, chronological degradation of metabolic processes leads to epidermal thinning, dermal hypocellularity, decreased numbers of dermal blood vessels, and decreased amounts of collagen and elastic tissue. aging results from thinning of the epidermis and dermis and loss of elasticity. This process affects all layers of the face, including subcutaneous tissue, the musculofascial system, the SMAS, and the facial skeleton. The result is bony resorption, atrophy of subcutaneous fat, attenuation of the musculofibrous system, and alterations of skin surface. The dermal-epidermal junction flattens, which results in loss of rete ridges and a thinner appearance to the epidermis. The dermis also becomes thin, with a decrease in elastic fibers, collagen production, vascularity, and ground substance. The biochemical alterations in collagen and elastin result in a dermis that is more lax yet less elastic and resilient. Collectively, these changes result in fine wrinkling of the skin and sagging of the tissues that overlay the facial skeleton. (skin atrophy, pallor, and loss of elasticity). o Extrinsic aging (Photoaging) from years of sun exposure and other external factors leads to the deposition of abnormal elastic fibers, the degeneration of collagen, and the twisting and dilation of microvasculature. Environmental damage to skin occurs as short-term and long-term changes: short-term, the response is inflammatory subside rather quickly in the skin, but continuous damage can result in prolonged inflammatory responses (subacute): postinflammatory hyperpigmentation. water volume, proteoglycans and glycosaminoglycans skin volume. The true long-term damage = water volume and in damaged cutaneous proteins. In particular, the elastic fibers tend to form tangled masses of nonelastic elastin remnants volume of skin without functional elements solar elastosis or heliosis (observed histologically) is the end stage of this damage. Scarring and remnants of proteinaceous elements tend to be the end stage of cutaneous disease. Although contracture is present, the general trend in environmental damage is thickness of skin, (especially of the dermis) with nonelastic and structurally weak skin. Sun damage, especially from UV-A wavelengths, causes ionization and oxidation of dermal elements and genetic information premalignant and malignant skin lesions.

Many years of acne (both cystic and rosacea) blood flow to skin hypertrophy the basic elements + Scar tissue deposits and can contract uneven skin surfaces True cysts and sinus tracts commonly result ice pick lesions as end stage. Heliodermatitis is a term applied to the chronic inflammatory changes and degradation of elastin and collagen observed in photodamaged skin. Photoaging can also damage DNA, which increases the risk of squamous and basal cell carcinoma. Both a rough surface texture with wrinkling, scaling, dyspigmentation, telangiectasias, and skin laxity. The accumulation of free radical damage probably plays a major role in both intrinsic and extrinsic processes. Underlying anatomic structures sag as deep layers loosen and subcutaneous fat accumulates or atrophies. Furrows develop in the skin that overlies facial muscles. Surgically lifting the skin and subcutaneous tissue, rearranging the distribution of facial fat deposits, and paralyzing facial muscles with botox are effective methods of addressing the underlying structural changes associated with aging, but they do not directly address the degradation in the quality of skin. One method of improving the condition of the skin is by "resurfacing" it, by removing the outer layers to the level of the papillary dermis reepithelialization and new collagen formation create a smoother, pinker, and more youthful appearance. Chemical removal of skin layers with peels (eg, trichloroacetic acid, phenol) and mechanical removal (ie, dermabrasion) are effective modalities for facial rejuvenation. Resurfacing can be used as an adjunct to facial surgery, or it can replace facial surgery when surgery is inappropriate or not desired by the patient.

LSR can be performed as an isolated procedure or as an adjunct to procedures such as transconjunctival blepharoplasty (TCB), facelift, and endoscopic browlift. Although this technology is relatively new, its benefits are clear. The LASER allows for precise control of ablation depth, and it permits the surgeon to vary these depths as needed, causes favorable heating of the dermis, which tightens collagen fibers and stimulates neocollagen secretion by fibroblasts. The popularity of dermabrasion has diminished with: o prevalence of blood-borne pathogens o is a technically difficult to maintain the proper depth. o The only absolute indication for dermabrasion is traumatic tattooing. While superficial peeling agents (eg, glycolic acid) remain popular, the use of medium and deep peeling agents has diminished. Currently, 2 LASER wavelengths are in common use for facial skin resurfacing: pulsed CO2 and erbium:yttrium-aluminum-garnet (Er:YAG). The practice of combining these wavelengths in sequence is also gaining popularity. (The latest generation of resurfacing LASERs combines Er:YAG with subablative CO2 energy in the same unit). Combined CO2 and Er:YAG LASER deliver both Er:YAG and subablative CW CO2 beams simultaneously (K blend mode) to the same tissue area. Advantages: 1. the precise tissue ablation and minimal necrosis of Er:YAG systems, coupled with the favorable heating of deeper tissue layers typical of CO2 systems. 2. the nuisance of oozing with Er:YAG alone is avoided with the addition of coagulative CO2 effects. 3. a reduced number of passes is required to reach depths equivalent to the Er:YAG alone.

4. clinical impression is that patients achieve skin-tightening effects between that of the CO2 and Er:YAG, with healing times closer to that of the Er:YAG. CO2 and Er:YAG LASERs in sequence following CO2 passes with Er:YAG removes the zone of thermal necrosis and promotes prompt healing. Clinical experience reflects the histologic findings of using this in vivo model showed that decrease in elastosis and increase in neocollagen was highest when pulsed CO2 was incorporated in the treatment session. INDICATIONS The CO2 LASER: 1. perioral vertical furrows 2. periorbital dynamic lines (crow's feet), ensure the patient understands that benefit is apparent only when in repose; that is, the furrows reappear upon squinting (unless botox type A is also used) 3. mild dermatochalasis, 4. glabellar dynamic lines 5. actinic damage 6. generalized facial elastosis 7. shallow scars 8. epidermal-dermal lesions.. Er:YAG skin resurfacing: actinic damage and/or superficial rhytids . An equally important factor is patient request for early recovery; that is, patients may want LASER treatment but request that they not appear red for months. Unlike the CO2 LASER, Er:YAG appears safe for use on the skin of the neck, chest, and hands, which expands its role. incidence of hyperpigmentation with skin types IV and V may be associated with use of the Er:YAG. The patient's wrinkle severity is classified preoperatively. Repeat treatments may yield the most optimal results. (spaced 4 months apart) The patient's sun-reactive skin type (Fitzpatrick) is recorded preoperatively. Unlike Er:YAG, full-face treatment is strongly preferred with CO2 (alone or in combination) to avoid demarcation lines. This not only improves camouflage while healing, it avoids obvious differences in skin quality and small step-offs between adjacent regions. Contraindications: Absolute contraindications include: o active acne o deep acne pits or picks, o Accutane use in the past 2 years. Accutane is effective for cystic acne because it targets the sebaceous glands. Yet, a compromise in gland function impairs skin reepithelialization and increases the risk of scarring. o History of herpetic infection (is only a relative contraindication) Clinical assessment: Obagi skin classification: [CTFFO] Degree of photoaging: Assess by judging type and degree of wrinkling, benign skin lesions (e.g. seborrheic keratosis, solar elastosis, senile comedones, telangiectasia), precancerous lesions (e.g. actinic keratosis), yellowsh discoloration, mottled hyperpigmentation, and skin laxity. In general, patients with early

photodamage do not require CO2 LASER resurfacing. (The ideal patient has mildto-moderate photoaging). Paucity of adnexal structures (skin poor in pores, hair follicles, oily glands): occur in
some skin types or can be related to a previous deep resurfacing procedure or radiation therapy.

Significant lower eyelid laxity: Avoid aggressive CO2 LASER resurfacing on the lid to
avoid postresurfacing scleral show and ectropion.

Past History of: o herpes labialis infection: Start suppressive therapy with oral antiviral medications 1-2 days before procedure and continue until complete reepithelialization takes place. o frequent vaginal candidal infections: Administer prophylactic course of oral antifungal
medications to affected patients.

hypertrophic scars or keloids: Avoid resurfacing deeper than papillary dermis. Allergies: Investigate allergies to local and systemic anesthetics properly. Select patients with realistic expectations & avoid patients with psychological instability
o o

Precautions: 2 treatment factors: First, always maintain a balance between results and morbidity. o Take care on the eyelids to avoid a full-thickness injury or cicatricial ectropion. o If significant dermatochalasis exists, then consider a blepharoplasty. o If severe facial elastosis is present, then consider a rhytidectomy. Second, never use a watts (CO2) or joules (Er:YAG) per pulse setting below that recommended for the handpiece being used. Remember that sufficient energy is required to reach the fluence necessary for char-free ablation. Turning the power too low forces heat into the tissue instead of the LASER vapor. Er:YAG LSR treatment is not painless, but it is significantly less painful than that of CO2. A eutectic mixture of local anesthetics (EMLA) cream (topical lidocaine) applied 2 hours prior to the procedure provides sufficient topical anesthesia. When working in the periorbital area, use metallic LASER eye shields for protection of the globes. Use tetracaine 0.5% ophthalmic drops for topical anesthesia; lubricate the shields well to avoid corneal abrasions. Physicians and assistants should wear goggles with protection specific for the wavelength(s) being used. allow no oxygen on the field because it will ignite a fire. CO2 The endpoint is reached when the lesion base has been removed or when a depth to the mid reticular dermis has been achieved (ie, whichever comes first). This depth is denoted by a chamois-brown color and may yield pinpoint bleeding spots. Treat wrinkles by direct LASERing into the furrows, a light pass (not to deepen the furrow + remodel the furrow base favorable dermal collagen heating). Next, flatten the wrinkle shoulders using the LASER as a planing tool. Finally, in a regional procedure, blend the aesthetic unit within its boundaries for optimal camouflage. If a full-face procedure is performed, take care to feather the inferior

boundary approximately 2 fingerbreadths below the jaw line to avoid a sharp demarcation line. Likewise, take care to extend treatment into the facial hairlines. Moisten the hairline and the eyebrows to avoid singeing because the popping and plume can disturb the patient. Er:YAG The technique is similar to that of CO2, except pulses are overlapped by 10%. A useful depth indicator is pinpoint bleeding that occurs when in the papillary dermis. (lack of coagulation properties in CO2) Derma K (combined) Same but Fewer passes are required because of the presence of subablative CO2 energy. Oozing rarely occurs because of these heating properties. CO2 and Er:YAG in sequence This is a simple technique of using the CO2 as the primary resurfacing LASER, followed by Er:YAG to remove the zone of thermal necrosis. (CO2 one pass then 2-3 passes of the Er:YAG). Postoperative details: an occlusive dressing to promote moist healing, Remove the closed wound dressing after 2 postoperative days. For superficial Er:YAG peels, apply Bactroban 2% ointment to keep the face moist for these first 2 days. For periorbital peels, apply Tobramycin 0.3% ophthalmic ointment to keep the region moist for 2 postoperative days. After 2nd postoperative day, the patient must wash the face 2-3 times a day with Cetaphil soap. not to rub the skin & apply a UV-A/UV-B sunscreen SPF >25 for 1 year. COMPLICATIONS Erythema Hyperpigmentation Infection Scarring FUTURE TRENDS The newer nonablative LASERs, such as the frequency-modified Nd:YAG, the broadband high-intensity pulsed light, and the flashlamp dye LASER, have been reported to affect dermal collagen without resultant exfoliation. A noted benefit is the marked reduction in recuperative time, allowing patients to be treated and return to work within their lunch hour. A more recent technology incorporates the use of a radiofrequency system to tighten skin and reduce wrinkles with the deposition of new and remodeled collagen. BOTOX is a useful adjunct to LSR for hyperdynamic facial lines such as crow's feet. Transconjunctival blepharoplasty (TCB) and periorbital LSR surfacing are an excellent combination because they address the 2 most common problems of the aging lower eyelid: TCB for pseudoherniated fat and LSR for mild skin laxity. The combination of rhytidectomy and LSR is another excellent option.

 The clinical effects of LSR, thought primarily to result from heat-induced immediate collagen tightening and initiation of a wound-healing response to injury, may result, in part, from cytokine secretion at the cellular level. At a fluence of 4.7 J/cm2 (commonly used in LSR), secretion of basic fibroblast growth factor (bFGF) & of transforming growth factor beta-1 (TGFB1) in both keloidproducing and normal dermal fibroblasts. The known ability of bFGF to promote organized collagen bundles may account for the observed clinical and histologic effects with LSR. In addition, the of TGFB1, which causes tissue fibrosis, may have a protective role in minimizing scar production during the healing process. The LASER can be considered a biostimulator that initiates a wound healing response.

Notes on CO2 LASERs

Technology and systems Two different types of CO2 LASERs are used for skin resurfacing: a high-power pulsed CO2 LASER that can deliver approximately 500 J of energy in each submillisecond pulse, resulting in energy fluence measuring 5-7 J/cm2. Some of these systems have a computerized pattern generator (CPG) that rapidly and precisely can place individual LASER pulses in several different patterns. an optomechanical flashscanner connected to a conventional CW CO2 LASER: This scanner efficiently distributes LASER energy into a train of pulses with a dwell time < skin TR, thus mimicking truly pulsed CO2 LASERs. Recently, CO2 resurfacing LASERs with very short pulse duration (60 microsecond) have emerged; they ablate less tissue per pass and leave behind a narrower zone of thermal necrosis than original CO2 LASERs. Mechanism of action of CO2 Laser: As with other resurfacing modalities, such as chemical peeling and Dermabrasion: completely removing the epidermis and part of the dermis wound remodeling with subsequent new collagen and elastin fiber formation healthier, firmer, and tighter skin Heat-induced collagen shrinkage during LASER resurfacing procedure, whether this immediate shrinkage observed clinically persists or results in long-term collagen tightening is not known. INDICATIONS of CO2 Ideal candidates: middle-aged patients (40-65 y) with fair skin and fine-to-moderate static (nondynamic) wrinkles, with realistic expectations, such as those who seek improvement rather than complete eradication of wrinkles or scars. 1- Rhytids

 Alone for mild-to-moderate surface texture changes and fine superficial or moderate static
wrinkles (not in those with deep furrows or severe dermatoheliosis). with BOTOX for dynamic rhytids with cervicofacial rhytidectomy and/or brow lifting for advanced skin + muscle laxity.

2- Scars
Acne scars can be classified into 3 basic types: (1) shallow depressed scars, (2) wide-base atrophic scars, (3) ice-pick or fibrotic scars. The first 2 types of acne scars + (Scar base lifting and injection of filling substances for atrophic acne scars) Varicella and smallpox scars. N.B. ice-pick scars often require punch excision, punch grafts, or punch elevation.

3- Dermatoheliosis
facial rejuvenation of photodamaged skin with detectable improvement of fine lines and wrinkles, mottled dyspigmentation, rough skin texture, and solar lentigines. can eradicate precancerous lesions e.g. actinic keratosis, (but not recurrence).

4- Other indications for CO2 LASER skin resurfacing include the following:

Seborrheic keratosis Verruca vulgaris/plana Sebaceous gland hyperplasia Angiofibroma (fibrous papule of nose) Junctional and compound nevi

Lentigo simplex Small syringomas Epidermal melasma Rhinophyma

Contraindications:
Absolute contraindications Active infections (bacterial, viral, or fungal) Tendency for keloid or hypertrophic scar formation Oral isotretinoin (Accutane) use within previous 1 year. Unrealistic expectations Uncooperative patient Relative contraindications Poor general health Fitzpatrick skin phototypes 5-6 Reticular dermis-level resurfacing procedure within preceding 2-3 months Unwillingness to accept possibility of postoperative erythema or hypopigmentation Significant eyelid laxity Excessively thick or thin skin Collagen vascular disease AIDS or hepatitis C infections

Preoperative details: At least 6 weeks before skin resurfacing, start a daily skin conditioning regimen: o Retinoic acid 0.05-0.1% cream (0.5-1g Retin-A) in evening o Hydroquinone 2-4% cream (0.5-1g Clear or Eldoquin Forte) twice per day, in morning and evening (not for patients who are light white [Fitzpatrick 1]) o Alpha-hydroxy acid 2-4% cream (0.5-1 g Exfoderm) in morning o Sun protection (SPF >15 sunblock) applied in morning Intraoperative details: Observe LASER safety at all times. o fire No flammable objects (eg, dry hair, dry gauze, alcohol) or oxygen. o Proper eye protection for patient, physician, and assistants.

Evacuation of vaporized tissue chance of airborne transmitted diseases. Clean patient's face with antibacterial soap. (isopropyl alcohol or acetone are flammable). Coat metal eye shields with sterile ointment chance of corneal abrasion. Cover periphery of face with wet cloths. Protecting teeth with wet gauze under lips chance of enamel damage. Anesthesia choices Topical anesthetics [EMLA] + local infiltration Regional nerve block + IV sedation (14 nerve blocks are required: supraorbital, supratrochlear, infraorbital, auriculotemporal, zygomaticofacial, mental, and cervical plexus bilaterally) IV sedation (Diprivan) Laryngeal mask airway + IV sedation and general anesthesia + endotracheal intubation are other acceptable methods of anesthesia. (Cover endotracheal and laryngeal mask airway tubes with wet towels). Technique parameters are set according to device, condition treated, skin type, and goal to be achieved. By achieving tissue vaporization in a single pulse, vapor that is created absorbs most of the heat generated, with resultant minimal diffusion of heat into the skin. Pulse stacking leads to cumulative thermal injury in the skin. When using a single spot hand piece, move it across the skin carefully and activate the LASER at a slow enough rate (4-10 Hz) to deliver single pulses with minimal overlap of subsequent pulses. Avoid overlap of the edges. Generally, the first pass results in the removal of the epidermis, leaving behind a narrow zone of thermal damage (10-30 m). Skin appears white with desiccated debris composed of epidermal tissue remaining after water evaporation. After the first pass, rehydrate skin with moist saline-soaked gauze, remove debris using gentle rubbing, then wipe treated area using dry gauze. Perform second pass in the same manner as the first pass; however, pulses may be oriented at 90 to the direction used for the first pass. In general, a third pass or subsequent passes can be applied more selectively to areas of advanced photodamage or scarring (shoulder of acne scars), often using a single spot handpiece. Relationship between number of LASER passes and tissue ablation/thermal damage is not linear. The first pass significantly ablates > the second or subsequent passes; an ablation plateau is reached in 3-4 passes, limiting ablation depth to 250 m. Resurfacing of a single area alone generally is not advised to avoid sharp demarcations. (Aesthetic units). Perform feathering of margin prevent demarcation lines. LASER resurfacing endpoints are as follows: o Cosmetic endpoint is the ablation of the target (eg, scar, wrinkle). o Safety endpoint is the appearance of a chamois yellow skin color that persists after wiping with a saline-soaked gauze. Postoperative details: Oral antibiotics, antiviral medications, and oral analgesics. Oral anti-inflammatory medications ??. Oral anxiolytics??.
o

Remind patients to avoid picking at their skin and to avoid rubbing skin vigorously when cleaning it or while in the shower. Dressings are used as follows: o as second-degree thermal burn. o Keeping the wound moist promotes faster reepithelialization. o In general, 2 methods of wound dressing exist. Open technique: Closed technique: Apply semiocclusive biosynthetic dressing e.g. polyurethane films (Silon II), hydrocolloids (Flexzan), and hydrogels (Vigilon). COMPLICATIONS Sequelae 1. Swelling: 2. Erythema 3. Itching (pruritus): (eg, mometasone furoate 0.1% [Elocon]). 4. Acne flare/milia: 5. Postresurfacing hyperpigmentation True complications 1. Infection (bacterial, viral, yeast, fungal) 5. Hypertrophic scars and keloids 2. Contact dermatitis 6. Ectropion and scleral show 3. Hypopigmentation 7. Tooth enamel injury: 4. Sharp demarcation lines: 8. Corneal abrasion/injury:

Newer resurfacing modalities (3)

Ablative
2 10,600 nm

Non-ablative

Electrosurgical skin resurfacing (Visage) coblation 70-80 m to the upper papillary dermis

CO

Er:YAG
2,940 nm 250-500 Sec 25-30 m 4-5 m

Nd:YAG
1320 nm (pulsed) 1064 nm (CW)

IR spectrum (wavelength) Pulse duration ablation of tissue (depth) thermal conduction (extend) Mode of action

CW or sub-miliSec 50-100 m 30-50 m vaporizes extracellular water in the dermis thermomecanical thermomecanical

pass

Collagen contraction

generates a decreased vaporization depth with each pass 14-25% immediate and

directly absorbed by induce a certain degree selective lesional collagen and dermal of thermal collagen tissue damage by proteins coagulation in the radiofrequency photomechanical photomechanical" papillary dermis while waves while +Dermal vessels generally sparing the inflicting minimal nonablative damage on dilatetransudation epidermis (nonablative adjacent resurfacing) collagen resurfacing of fluidwater structures. contracture and content subsequent (chromophore) in neocollagenesis. the treated area allows for consistent ablation with each subsequent pass Each pass generates the same amount of ablation

1-2% immediate and 14% late

Disadvantages

late

neither can induce the same collagen tightening nor impart the hemostasis

Multiple treatments are required over many weeks to achieve an optimal result

??????

Coblation differs from Laser resurfacing by the almost complete lack of heat generated by the former, theoretically decreasing the likelihood of erythema and other postresurfacing complications. Today, physicians use 5 LASER modalities for ablative skin resurfacing: Scanned CO2 LASER Fractional Er:YAG LASER Pulsed CO2 LASER Combination CO2 and Er:YAG LASERs Pulsed Er:YAG LASER Mode of action: controlled vaporization of the skin according to the principles of selective photothermolysis (The target tissue contains a chromophore with an absorption peak that selectively absorbs the particular wavelength of the LASER pulse, whereas the tissue surrounding the chromophore absorbs the energy to a much lesser degree). The interaction of the target tissue with the energy of the CO2 LASER is transformed mostly into a thermomechanical reaction that destroys dermal vessels and denatures dermal proteins. the Er:YAG LASER, the interaction involves a photomechanical reaction. Absorption of the energy causes immediate ejection of the desiccated tissue from its location at a supersonic speed, creating a characteristic and almost startling "popping" sound. This translation of Er:YAG LASER energy into mechanical work is an important factor that protects the surrounding tissue; minimal thermal energy remains to dissipate and cause collateral damage. Newer Er:YAG LASERs with longer (500 m) and variable pulses have been developed. They have better tissue penetration, which makes deeper tissue ablation less difficult. They create larger zones of thermal necrosis, leading to more collagen contraction and better remodeling. Another improvement is in the shape of the energy distribution within the LASER beam; some LASERs distribute the energy in a uniform, or "top hat," pattern rather than in a gaussian pattern. The uniform pattern is thought to provide better hemostasis. Perioral rhytides reflect generalized atrophy. Restoration of a "level playing field" with subdermal grafts ("fresh," nonrefrigerated autologous fat,) and intradermal filling (hyaluronic acid, human collagen injections), as well as mild derma planning, reduce the resurfacing required, thus reducing the number and severity of complications. Many LASER surgeons use a 3- to 5-mm spot size, a pulse energy of 1-2 J, and a pulse repetition rate of 1-10 Hz. A fluence of 5 J/cm2 per pass is usually used in delicate areas such as the periorbital and preauricular regions or for superficial lesions. Higher energies (12-15 J/cm2 per pass) are used in thicker, more heavily photodamaged or scarred areas such as the cheeks, chin, perioral areas, and forehead. The epidermis can be completely ablated after 2 or 3 passes severely damaged skin, deep rhytides or scars, and deep dermal growths may require as many as 20 passes. Higher-energy Er:YAG devices with a fluence of 20 J/cm2 have been developed that can ablate most of the epidermis after only one pass and, with subsequent passes, produce some dermal ablation with minimal thermal injury.

Intense pulsed light

Intense pulsed light systems uses light within the wavelength spectrum of 511 to 1100 nm emitted from a pulsed or flashlamp source.

 Settings similar to laser settings can be altered (pulse width, fluence, and spot size) to obtain similar clinical results. Nonablative therapies: the varying targets of IPL, that is, hemoglobin, melanin, and water, resulting in improvement in coloration or pigmentation rather than changes in the underlying collagen structure. IPL technology is characterized as being more useful to the prevention or prophylaxis, or both, of the effects of photoaging. Additionally, IPL may require maintenance treatments and longer follow-ups to determine the most effective treatment patterns. IPL is a safe and beneficial procedure for patients with darker skin types (Fitzpatrick types IV and V) treated for photoaging, there was a subjective improvement in pigmentation without the side effects of postinflammatory hyperemia or hyperpigmentation. Another IPL (Fitzpatrick types III and IV) with postburn hyperpigmentation treated with IPL demonstrated a 50% improvement, no patient experienced repigmentation and some patients noted an improvement of scar texture in addition to the improvement in color. Reported side effects included (1) no response and (2) blisters and erythema that resolved within 7 days without permanent scarring.

Skin cooling
An important adjunct to laser technology in facial plastics is skin cooling. Skin cooling allows the delivery of increased energy to the skin/lesion while minimizing the damage to the epidermis. these adjuncts allow the delivery of greater energy to the targeted skin in Fitzpatrick skin types IIV. an added benefit of skin cooling is increased patient tolerance because of the reduction of pain.

Nonablative Facial Skin Tightening

CO2 & Er:YAG LASERs are ablative facial resurfacing. (the epidermis is denuded to a certain depth by the direct physical, chemical, or thermal injury applied to the skin healing response deposition of a new skin matrix (by a proliferation of fibroblast activity, the action of inflammatory mediators, and a deposition of new collagen and other dermal matrix proteins). Despite achieving appreciable clinical results, the adverse effects of ablative resurfacing modalities can result in significant edema and erythema that last for several weeks. the typical prolonged recovery times and the potential problems associated with these ablative modalities may also limit their use in patients who desire a rejuvenation procedure with reduced downtime and a minimal risk profile. In contrast, nonablative LASER rejuvenation procedures induce a dermal healing response without notable injury to the epidermis. The exact mechanisms of nonablative dermal remodeling are still under investigation; however, a subthreshold LASERinduced injury to the dermis and/or the dermal vasculature theoretically, a wound repair response, fibroblast stimulation, and collagen reformation. the mid-infrared range may be the best choice for safe nonablative resurfacing on a wide range of skin types e.g.: o 1320-nm Nd:YAG LASER o 1064-nm Nd:YAG LASER LASER energy in the near- and mid-infrared locations is weakly attracted to melanin. epidermal melanin is bypassed more efficiently, all skin types can be treated, risk. Also, by extending the wavelength to the infrared and mid-infrared areas deeper energy penetration can be achieved LASER energy can be delivered to the dermis.

 Theoretically, heat-induced dermal injury dermal fibroblasts healing response collagen remodeling and an improvement in the appearance of facial rhytids. SKIN-COOLING TECHNIQUES COUPLED WITH ND:YAG LASERS o Coupling the 1320-nm Nd:YAG handpiece + a thermal sensor + a cooling cryogen blast allows the surgeon to better control the surface temperature of the skin LASER is able to induce greater thermal stimulation of dermal fibroblasts within the papillary dermis and the mid-reticular dermis, while cooling the epidermis and protecting it from direct thermal injury.

Skin Resurfacing: Dermabrasion

Dermabrasion is the process of mechanically removing the damaged outer layers of skin. The epidermis then regenerates from the epidermal appendages located in the remaining dermis. Indications and advantages: o surgical or traumatic scarring o acne pits & scars (those are narrow, pitted, and cast a shadow on the face) o rhinophyma o chickenpox scars o premalignant actinic damage o melasma o tattoos (both traumatic and intentional) o perioral rhytids o Whereas chemical peeling and LASER resurfacing usually are applied globally to the face, dermabrasion more often is used for specific areas of troubling scarring or wrinkling. Dermabrasion is used for specific areas of the face more often than LASER resurfacing or chemical peeling because dermabrasion does not injure melanocytes and is less likely to cause pigmentation changes. o LASER resurfacing and chemical peeling, when applied to only a portion of the face, often leave lines of demarcation between treated and untreated regions, denoting damage to melanocytes in the treated areas. o In addition, dermabrasion is much less costly to the patient than LASER resurfacing or chemical peeling. Several variables are critical in determining the depth this outcome, including: 1. the coarseness of the dermabrading tip (fraise) 2. number of brush strokes 3. pressure exerted on the electric handpiece 4. tissue contact time.

Suggested rotational speeds: 12,000-15,000 rpm

Diamond tips of varying sizes, shapes, and coarseness are used most commonly.

COMPLICATIONS Results and complications generally are related to the depth of wounding, with deeper wounding providing more marked results and a higher incidence of complications. o Erythema, o hyperpigmentation, o Hypopigmentation (is the result of melanocyte destruction or inhibition. Being of neural crest cell origin, these cells do not possess the ability to regenerate or divide). o Delayed healing hypertrophic scarring, o Infectious complications are unusual but demand vigilance and aggressive therapy with oral and topical antibiotics. o Milia, ie, intraepidermal collections of keratinaceous debris, appear as small white cysts. Treatment consists of lancing the cysts with a needle or scalpel.

Microdermabrasion
All resurfacing procedures exert their effects through different degrees of epidermal and dermal ablation. The results and the indications for each modality depend on the depth of ablation. The microdermabrasion technique abrades the skin with a high-pressure flow of crystals Microdermabrasion was developed in Italy in 1985. This technology offers the advantages of low risk and rapid recovery compared with more traditional resurfacing modalities and can be effective in the appropriate patient population. the advantages of microdermabrasion: (1) does not require anesthesia, painless, (2) can be repeated at short intervals, (3) is simple and quick to perform, (4) does not significantly interrupt the patient's life. Disadvantages: Microdermabrasion produces a superficial ablation, primarily in the epidermis; therefore, this procedure is ineffective for deeper wrinkles or scars. However, for fine lines and more superficial scars, microdermabrasion can be effectively used

Skin Resurfacing, Chemical Peels

Pathophysiology: The mechanism of action of peeling agents is relatively straightforward. Stronger agents such as phenol (with various additives such as croton oil and glycerin) and trichloroacetic acid (TCA) chemical necrosis to variable depths, (depending on a number of controlled and uncontrolled variables). Weaker agents (eg, AHAs) change the pH sufficiently to cause a superficial shock to the cells and, (depending on many variables) cell injury or death. Acids: When used with a moisturizer cause cellular and intercellular swelling and plumping transient in cell and matrix size fine lines and rhytides Sequential treatments lead to exfoliation and a smoother complexion. Continued irritation can lead to many of the same effects of tretinoin or retinoid treatment (ie, thickness of dermis, blood flow to skin). Alkali: The phenol peel deserves special consideration: The Baker formula published in 1962 is as follows:
United States Pharmacopeia (USP)

Phenol USP 88% 3 ml 49% distilled water 2 ml 44% croton oil 3 gtt 2.1% (if 1 gutta = 27 drops/ml) Septisol (liquid soap) 8 gtt 4.5%. Septisol acts to decrease surface tension and thus increase absorption Croton Oil from the seed of the plant Croton tiglium, may enhance phenol absorption and cause inflammation Criticism of the formula:

1. Phenol was the only active ingredient. 2. Lower concentrations of phenol penetrate deeper than higher concentrations ??? due to the denaturation of superficial proteins with higher concentrations nonpermeability of the remainder of the solution. (as acid X) i.e. Lower concentrations are more dangerous (X). 3. Septisol (a detergent or surface tensionlowering agent) causes deeper penetration. 4. Croton oil is present only as an irritant. Clinicians now know that phenol actually peels deeper in higher concentrations. Septisol causes deeper penetration of phenol and a deeper peel. Croton oil (especially the toxic fraction solubilized in phenol) causes a deeper peel.

INDICATIONS ? The ideal candidate has minimal sag or severe skin excess but many fine lines and rhytides. Contraindications: hypersensitivity to the peeling agent, presence of facial cancers, with an absolute contraindication in a patient with a facial melanoma or a skin condition such as pemphigus. Deep phenol peels over extensive areas large amounts of phenol absorption fatal cardiac arrhythmias. Therefore, Monitoring is necessary during panfacial procedures. WORKUP Lab Studies: Routine. Other Tests: If an extensive area is to be peeled with phenol, perform a preoperative ECG and intraoperative monitoring. TREATMENT Classification of peel depth Very superficial: exfoliates statum corneum Superficial: between strata granulosa and basale Medium: papillary or upper reticular dermis Deep: Midreticular dermis

Factors that Affect Depth

Agent used Method of application and number of layers Pre-peel degreasing Pretreatment retinoids or hydroxy acids Skin thickness Sebaceous gland activity and density Anatomic unit Other factors that affect the depth of peel include presence of skin surface oils and dirt skin water content temperature of the room, skin, and solution humidity of the air length of time the solution is left in contact with the skin occlusion or nonocclusion batch of croton oil thickness of epidermis and dermis presence of hyperkeratotic lesions.

Which Agent to Use?

Phenol Bakers peel Jessners solution TCA 10-35% Modified Unnas resorcin paste Jessners + TCA CO2 + TCA Solid carbon dioxide Alpha hydroxy acids Alpha keto acids Tretinion 70% Glycolic + TCA TCA 50% Azelaic acid

Very Superficial TCA 10-20% 1-2 layers Jessners 1-3 layers Glycolic acid 20-30% for 1-2 minutes Superficial TCA 20-30% Jessners 4+ layers

Glycolic acid 40-50% for 220 minutes

Medium TCA 30-40%, or 50% TCA Plus Jessners Glycolic acid CO2

Deep Phenol Baker-Gordon

Unoccluded Occluded

Superficial skin peel Indicated for: Comedonal acne Melasma Skin refresher Nonfacial peeling Repetitive peels may promote collagen stimulation Low-risk, rapid recovery Medium and Deep skin peel Indicated for: o Actinic changes and preneoplasia o Rhytides (fine) o Pigmentary dyschromias o Woods lamp helpful o Superficial scarring o Radiation dermatitis o Acne vulgaris and rosacea Pretreatment
Hydroquinone Decreases melanosomes and inhibits tyrosinase Useful in Fitzpatrick III and IV to prevent hyperpigmentation Begin 1 mo pre-peel and continue post-peel Anti-virals Tretinoin (topically) has been shown to: Correct epidermal atypia Thicken atrophic epidermis Eliminate microscopic actinic keratoses Cause uniform dispersion of melanin granules Increase collagen in papillary dermis Increase angiogenesis Systemic isotretinoin (Accutane) inhibits collagenase and decreases the sebaceous units Much more likely to scar with chemical peel Recommend waiting 1-2 years before peel

ALPHA HYDROXY ACID (AHA) PEEL The typical alpha hydroxy acid (AHA) peel involves the use of glycolic acid, which is derived from sugar cane, at concentrations of 50% or higher. Subsequent exfoliation occurs over several days. Over-the-counter AHA products containing 3-10% glycolic acid or other naturally occurring organic acids (lactic acid, citric acid, tartaric acid, malic acid) cause exfoliation over several weeks and actually may be used as a pre-peel primer to potentiate the effects of application of a higher concentration. Unlike other peeling agents, penetration of glycolic acid is time dependent; thus, the agent is applied for a specific amount of time and then neutralized. The length of time that glycolic acid is left on the skin relates to concentration, with increasing concentrations achieving the desired results in less time. The systematic application of glycolic acid with a sponge typically proceeds from one facial region to another divide the face into 6-8 regions and treating each succesfully. Following application, an initial erythema may become frankly red, often accompanied by edema. White patches subsequently develop, indicating epidermolysis with

separation of the epidermis from the underlying dermis. Development of a frost indicates depth of destruction into the dermis and is not desirable, as this is meant to be a relatively superficial peeling agent. Exfoliation typically occurs over several days, and re-epithelialization is complete within 7-10 days. Multiple treatments may be required to achieve the desired results and should be spaced several weeks apart. Glycolic acid peels produce the least profound results but also are associated with the lowest frequency of complications. Removal of the agent is achieved by washing off the agent with water or neutralizing it with an alkaline solution such as sodium bicarbonate. TRICHLOROACETIC ACID (TCA) PEEL Trichloroacetic acid (TCA) is typically used as: o intermediate-to-deep concentrations ranging from 20-50%. o deep 50% TCA penetrating into the reticular dermis. Concentrations > 35% are not recommended because of the high risk of scarring. TCA is a keratocoagulant that produces a frost or whitening of the skin, (depend on concentration used). Works by precipitating proteins Vigorous rubbing of the agent, as compared to blotting, yields a deeper penetration. This technique is not time dependent, and the agent does not require neutralization. The systematic application with a sponge (the face in a succession of 6-8 regions). TCA application is associated with an intense burning that usually resolves within 30 minutes preoperative analgesia + regional nerve blockade + cooling (fan) + iced saline prior to moving from one facial region to another. During the procedure, if the frosting is not uniform or complete, reapplication may be performed until frosting of a desired plateau is reached. Once completed, exfoliation proceeds for several days, and re-epithelialization is complete within 10-14 days. PHENOL PEEL Phenol peels may be performed with various formulations: o pure phenol (88%) o phenol mixed with soap, water, croton oil, and sometimes olive oil. o formulas have such names as Baker-Gordon, Venner-Kellson, MaschekTruppman, and Grade. Phenol causes keratolysis and keratocoagulation. In contrast to other agents, concentration of phenol actually the penetration up to a point. Pure phenol does not penetrate as deeply as the various formulations. Occlusion with a waterproof mask deepen the level of the peel re-epithelization time and posttreatment erythema. So, open management is advisable. Similar to TCA, the time spent applying the agent and the amount of sponge strokes used will be proportional to the depth of penetration. The addition of croton oil to the various formulations as a skin irritant also allows deeper penetration. Although phenol produces the most remarkable resolution of actinic damage and wrinkling among the various chemotherapeutic agents, it also possesses some of the more significant morbidities. Marked hypopigmentation in all skin types, noticeably lightening the skin of patients with darker skin and making lighter-skinned patients appear waxy or pale. A clear line of demarcation may be present between treated and untreated skin. Phenol causes an intense burning upon application that may last 4-6 hours, The toxicity of phenol may be significant:

through skin metabolized by liver excreted by kidneys. may lead to myocardial irritability Overdoses may injure the liver and kidney and, cause arrhythmias. Some practitioners preload the patient with fluids to facilitate renal clearance + monitor patients during the procedure and in the immediate recovery period. The face is again divided into 6-8 regions, but 20 minutes must be allowed to elapse between treating subsequent regions. This allows for some ongoing metabolism and avoids a toxic systemic dose. Complications: Salicylates: tinnitus, vertigo Resorcinol: circulatory collapse, hypothyroidism, methemoglobinemia Phenol: arrhythmias TCA: none Concentrated TCA (>35%) more likely to scar TCA less likely to cause pigmentary changes TCA less toxic

absorbed

Laser Versus Deep Peel peel is equally effective in thin-skinned areas Laser better in thick glandular skin but had more hypopigmentation, longer discomfort, longer postop erythema

LASER Revision of Scars

The wound-healing process is divided into 3 stages: inflammation, granulation tissue formation, and matrix remodeling. o The initial stage is defined by a structured sequence involving inflammatory cells. This cascade is orchestrated by neutrophils. o Subsequently, macrophages elaborate a variety of cytokines, which create an environment amenable to granulation tissue formation. o Finally, fibroblasts migrate into the area, proliferate, and recapitulate ontogeny by depositing new collagen, first type III and later type I. o Simultaneously, angiogenic factors released into the wound environment stimulate formation of new capillaries. o A problem arises when this organized process is disrupted. hypertrophic scars, keloids, striae, atrophic scars, and acne scars. Although scars rarely pose a health risk, patients often present with symptoms of associated pruritus or dysesthesia. LASER-tissue interactions produce 3 effects: photothermal, photochemical, and photomechanical.

 Photothermal effects, which are directly derived from heat production, are the primary focus of dermatologic LASER surgery. LASER TREATMENT OF SCARS AND STRIAE: BACKGROUND Anderson and Parrish's publication detailing the theory of selective photothermolysis. The first LASER used in hypertrophic scars and keloids was a CW-argon LASER. Similarly, use of the CW Nd:YAG LASER (1064 nm), [selectively collagen production by a direct photobiologic effect and creates tissue infarction with subsequent charring and sloughing of the treated area]. Results, however, were transient and scar recurrences were common. Similar recurrences were observed with a CW CO2 LASER. By the early 1990s, the effectiveness of the vascular-specific 585-nm pulsed dye LASER (PDL) in treating a variety of vascular lesions (eg, port-wine stain, telangiectasia) was widely known use of the 585-nm flashlamp-pumped PDL in the treatment of hypertrophic scars and keloids. Skin surface texture analysis performed by optical profilometry with accompanying clinical assessment revealed that LASER-irradiated scars approximated normal skin characteristics. No scar recurrences were noted 4 years following treatment. Assessment of scar by Vancouver Burn Scar Scale: vascularity, pliability, height, and cosmetic appearance. Histologic evaluation revealed increased numbers of regional mast cells. Because mast cells also elaborate a variety of cytokines, the presence of mast cells following LASER irradiation and accompanying tissue revascularization may provide an explanation for the therapeutic outcome following microvasculature destruction in terms of stimulating collagen remodeling Combiend therapy: PDL + CO2 LASER or PDL + intralesional corticosteroids.

Mode of action: No consensus exists regarding the mechanism by which PDLs achieve these additional clinical effects. Plausible explanations include: LASER-induced tissue hypoxia ( microvascular perfusion) collagenesis Collagen fiber heating with dissociation of disulfide bonds collagen realignment selective photothermolysis of vasculature mast cell factors (eg, histamine, interleukins, various immunofactors) that may affect collagen metabolism. 585-nm PDL to effect an improvement in the appearance of striae: o improvement in skin surface appearance o increased dermal elastin after low-fluence LASER irradiation. In a 1998 report, Alster and colleagues also found that low-fluence PDL irradiation was superior compared with pulsed dye treatment at regular (scar) fluences and pulsed CO2 vaporization. Both groups postulate that the improvement may be due to LASERinduced effects on elastin, collagen, or other undiscovered factors. SCAR CHARACTERISTICS Proper scar classification is important. Subtle differences in clinical characteristics indicate the diagnosis and treatment protocol.

o Qualities such as color, texture, and morphology affect the fluences used and the number of predicted treatments required for revision. o The physician should also consider the number and results of previous treatments. Hypertrophic scars raised, pink, firm, erythematous scars characterized by expression of collagenase. Occur due to: collagen synthesis + collagen lysis during the remodeling phase formation of thick hyalinized collagen bundles consisting of fibroblasts and fibrocytes. Collagen bundles are arranged in nodules. However, it remains within the confines of the original skin injury. Hypertrophic scars and their keloid counterparts usually form in body areas that exhibit slow wound healing or in pressure-dependent or movement-dependent areas. Scars usually form within the 1st month following injury. Unlike keloids, hypertrophic scars may regress over time. Approximately patients C/O: pruritus and dysesthesia. Keloids raised, reddish-purple, nodular scars that are firmer than hypertrophic scars. Occurs due to: prolonged proliferative phasean inherited metabolic alteration in collagen. thick hyalinized collagen bundles. extend beyond wound margins and do not regress over time. Keloids also contain hyaluronidase. Formation may occur over weeks or years following the initial trauma. occur in all skin types, keloids are most common in darker skin. Striae distensae or stretch marks, are linear bands of atrophic or wrinkled skin. Occurs due to: rapid weight loss or weight gain in areas that have been excessively stretched (abdomen, hips, breasts, and joints) Dermal inflammation and dilated capillaries mark the initial presentation an erythematous appearance with characteristic pink, lavender, and purple hues Later, striae appear hypopigmented and fibrotic. Pathogenesis remains unclear, although estrogen and mast cell degranulation with elastolysis may be contributing factors. Atrophic scars dermal depressions most commonly caused by collagen destruction during an inflammatory skin disease such as cystic acne or varicella. Surgery and trauma may also result in atrophic scars. Most patients attempt to camouflage lesions with makeup; however, scar appearance is often exacerbated by makeup, which enhances problematic textural variations. Acne scars Atrophic acne scars are the most common types. Less frequently, acne scars can be either hypertrophic or keloidal. Two major types of atrophic scars include: o superficial, erythematous macular scars typically do not require more than topical sunscreen or retinoids. o deeper scars resulting from a dermal process deeply occurring inflammation affects lower structures within the skin and leads to atrophy of the overlying skin. Atrophic acne scars can be classified into 3 basic types: shallow depressed scars, or rolling wide-base atrophic scars, or boxcar fibrotic scars, or ice-pick

 Rolling scars, tend to be shallower, wider (4-5 mm), and produce an undulating appearance in otherwise normal-appearing skin. This rise and fall of the skin surface is from abnormal fibrous attachment of the dermis to the subcutis. Boxcar scars are also wider than icepick scars, but they do not taper. These round- to oval-shaped skin dimples have sharp margins. They can be either shallow (0.1-0.5 mm) or deeper, but most tend to have diameters from 1.5-4.0 mm. Ice-pick scars are usually narrow (<2 mm), sharply demarcated tracts that can reach deep into the dermis or even the subcutaneous tissue. They are typically wider at the epithelial surface and taper as they go deeper. PATIENT VARIABLES Darker skin phototypes Hypertrophic scars and keloids affect approximately 4.5-16% of blacks and Hispanics. White-to-black susceptibility ratio estimated at 1:3.5 to 1:15. The presence of increased epidermal pigment in darker skin tones (phototypes > III) interferes with the absorption of PDL energy by hemoglobin: (1) efficacy of LASER is reduced, (2) destruction of epidermal melanin results in postoperative hypopigmentation. Concurrent inflammation or infection Infectious and inflammatory processes must resolve before performing LASER surgery. In cases of bacterial or viral infection (eg, herpes simplex, verrucae), the physician must consider that infection may koebnerize by LASER irradiation. In cases of concurrent inflammatory skin disorders (eg, cystic acne, psoriasis, dermatitis), the condition may worsen with LASER treatment, and dermal inflammation may impede postoperative healing and clinical effects. Medication use Patients with atrophic acne scars are likely to have a history of isotretinoin use. Isotretinoin can foster the development of hypertrophic scars because of its effect on collagen metabolism and wound repairpatients must stop it for -1 year. Unrealistic expectations Patients should realize that some degree of scarring persists and multiple re-treatments may not completely eradicate the scar(s). TREATMENT OPTIONS Remember red green & blue yellow Treatment of hypertrophic scars and keloids [585 nm PDL therapy]: Surgical technique calls for a series of adjacent nonoverlapping LASER pulses delivered across the entire scar breadth. Treat the entire scar at each session. The scar's size, thickness, location, and color, as well as the patient's skin type, determine energy density. Less fibrotic scars in sensitive skin areas (eg, anterior chest and breast) require lower energy densities; thicker or darker scars can be treated with slightly higher fluences In general, treatments should begin at lower fluences, allowing for flexibility of upward adjustment depending on scar response. Postoperative purpura following treatment with the vascular-specific PDL usually resolves within 7-10 days. Most hypertrophic scars have an average of at least 50-80% improvement after 2 LASER treatments. Keloid scars and more fibrotic hypertrophic scars usually require additional LASER treatments to achieve desired results.

Treatment of striae [585-nm flashlamp-pumped PDL] respond best to lower energy densities (3 J/cm2). Adjacent nonoverlapping LASER pulses are delivered such that each individual stria is covered. Irradiated striae do not typically exhibit the characteristic purpura observed with the treatment of hypertrophic scars and keloids. Because of lower fluences, striae usually appear mildly pink, which represents mild postoperative tissue hyperemia and edema. Vesiculation and crusting should not occur when proper fluences and operative technique are used. Typically, only 1-2 treatment sessions are necessary to obtain desired results. Treatment of atrophic scars [CO2 and Er:YAG LASER] Through selective ablation of water-containing tissue, both LASER systems offer predictable reproducible vaporization of tissue, yielding better control compared to dermabrasion. During LASER resurfacing, the epidermis and a variable portion of the dermis are destroyed, with reepithelialization occurring from adjacent pilosebaceous glands. With the use of the CO2 LASER in particular, the production of increased numbers of myofibroblast and matrix proteins is enhanced as a result of controlled collagen denaturation (heating). Pulsed Er:YAG LASERs are 10 times more selective for water than their CO2 counterparts; therefore, they result in enhanced tissue vaporization and reduced residual thermal damage. Postoperative erythema is decreased; however, the limited photothermal effect on tissue is countered by an overall decrease in clinical improvement. Thus, short-pulsed Er:YAG LASER resurfacing falls short of delivering the collagen shrinkage, or tightening effect, observed with CO2 LASER treatment. Overall, the Er:YAG LASER is effective in resurfacing skin with mild atrophic scars Regardless of the system, goals are: to soften the transition between the atrophic indentation and the intact (normal) skin surrounding it to stimulate collagen production within the atrophied area. Once de-epithelialization is achieved (typically requiring 1 pass with the CO2 LASER at 300 mJ and 2-3 passes with the Er:YAG LASER at 5 J/cm2), the scar edges, or shoulders, can be further sculpted with additional passes. Cutaneous LASER resurfacing of moderate atrophic scars with the CO2 LASER yields a mean improvement of 50-80%. Collagen remodeling with further scar improvement may occur for 12-18 months postoperatively, so consider postponing re-treatment of residual scars for at least 1 year to accurately gauge clinical improvement. The Er:YAG LASER system, although effective in the treatment of mild atrophic scars, does not offer the same amount of collagen remodeling as CO2 system. The Er:YAG LASER should be reserved for sculpting of individual scar edges and treatment of mild acne scars. Erythema, hyerpigmentation (with darker skin tones), hypopigmentation are sequalae. Infection is another postoperative concern because reepithelializing skin is vulnerable to bacterial (eg, pseudomonas, staphylococci), viral (eg, herpes simplex), and fungal (eg, Candida organisms) infections. Incidence is lowered with appropriate use of prophylactic antibiotics and, more importantly, aggressive postoperative wound care. The most severe complications are hypertrophic scarring and ectropion formation (Hypertrophic burn scars can be effectively treated with 585-nm PDL irradiation as described earlier; ectropion typically requires surgical reconstruction). Treatment of acne scars [CO2 & Er:YAG and Nd:YAG and 585-nm PDL]

 In addition to LASERs, numerous modalities can be used to treat acne scars, including excision, subcision, cryosurgery, dermal fillers, chemical peels, and silicone sheeting compression. Icepick scars usually extend too deep into the dermis to be reached by conventional treatments and may require a punch modality for removal. rolling scars, therapies should be aimed at treating the irregular underlying anchoring between the dermis and subcutis. Therefore, LASER revision is usually limited to shallow boxcar and superficial scars. Ablative LASER resurfacing with either a CO2 or Er:YAG LASER The CO2 LASER can be used to first treat the scar, followed by irradiation with an Er:YAG LASER to further remodel the ablated tissue. In contrast to ablative resurfacing, nonablative LASERs (Nd:YAG) do not noticeably disrupt the skin's epidermis, but they deliver thermal energy and damage the underlying dermis. These LASERs collagen remodeling and production, which is predominantly collagen type III. In time, the collagen expression changes to contain a greater proportion of type I collagen. With these LASERs, clinical improvement usually requires more than one treatment and results can continue to improve months after the LASER treatments have been completed. 585-nm PDL could improve erythematous and hypertrophic acne scars 1 or 2 treatments (6-7 J/cm2; 7-mm spot size). Atrophic acne scarring has been treated with a 1064-nm Q-switched Nd:YAG LASER. average fluence of 3.4 J/cm2, 4- to 6-nanosecond pulse duration, and a 6-mm spot size. The sustained improvement is likely from an enduring dermal collagen remodeling after the LASER treatments have concluded. The long-term results and safety profile (ie, mild-to-moderate erythema, pain, pinpoint petechiae) allow this LASER to be a viable option for patients with mild-to-moderate atrophic acne scars. 1450-nm diode also used in atrophic scars (mild-to-moderate). Both LASERs are safe, noninvasive options to improve the appearance of mild-to-moderate facial atrophic scars. The 1320-nm Nd:YAG LASER with a built-in cryogen cooling spray has been used for acne scarring. Icepick scars without fibrosis responded more favorably than those with fibrous tracts. SUMMARY The 585-nm PDL is best used to treat hypertrophic scars, keloids, and striae. The pulsed CO2 and Er:YAG LASER systems effectively resurface atrophic scars. Clinical Responses of Scars to LASER Therapy
Scar Type Hypertrophic Keloid Striae Atrophic LASER Used 585-nm pulsed dye 585-nm pulsed dye 585-nm pulsed dye Number of Treatments 2-4 2-6 1-2 1-2

CO2 (10,600nm) Er:YAG (2940nm) Long-pulsed diode (1450nm) Long-pulsed Nd:YAG (1320nm)

Pulsed dye LASER treatment considerations and protocol Preoperative consideration o Skin types I-III are best suited for treatment. o Hypertrophic scars are more amenable to treatment.

Treat all body locations when possible. Patients should not take anticoagulants. Intraoperative considerations o In most circumstances, use topical anesthesia or no anesthesia. o Energy densities may be as follows: 4.5-5.5 J/cm2 (10-mm spot) 6.0-7.0 J/cm2 (7-mm spot) 6.5-7.5 J/cm2 (5-mm spot) o Deliver adjacent, nonoverlapping spots. Postoperative considerations o Patients should use a topical antibiotic ointment. o Advise the patient to use sunscreen and avoid sun exposure. o Evaluate for re-treatment at 6-8 weeks. o Consider bleaching for hyperpigmentation. CO2 or Er:YAG LASER resurfacing of atrophic scars Preoperative considerations o Skin types I-II are best suited for treatment. o This LASER is used for nonpitted atrophic scars. o Facial scars respond best. o Previously treated scars are more difficult to treat. o Patients should discontinue isotretinoin at least 6 months prior to treatment. o Patients should be free of concurrent infection and inflammatory disease. Intraoperative considerations o Intravenous anesthesia is used in most cases. o Use energies that exceed critical vaporization threshold (>5 J/cm2). o Remove partially desiccated skin between passes. o Dampen hair-bearing areas. o Avoid flammable substances. Postoperative considerations o Patients should use healing ointments and semiocclusive dressings. o Patients should use ice or cooling masks as needed. o Close follow-up is necessary. o Patients should frequently clean skin. o Consider prophylactic antibiotics and pain or sleep medications. o Observe for and treat adverse effects and complications as early as possible.
o o

Tattoo LASERs
Remember red green & blue yellow Etiology: 1. decorative or cosmetic tattoos. 2. Traumatic tattoos 3. iatrogenic tattoos placed for radiation ports or to camouflage birthmarks, Treatment modalities: Destructive and surgical modalities including topical acids, dermabrasion, cryosurgery, surgical excision, and infrared coagulators may all remove tattoo ink, but leave scars. Goldman pioneered laser treatment using a normal-mode ruby laser. Although their results were disappointing, subsequent attempts using a Q-switched ruby laser gave an improved outcome. Unfortunately, these results were ignored for approximately 15 years.

 Laser surgeons in the late 1970s and 1980s used CW argon and CO2 lasers to remove tattoos, but encountered scarring due to nonspecific thermal damage. In 1983, Reid use Q-switched ruby laser for tattoo removal and reported excellent cosmetic outcomes in blue-black and amateur tattoos. In the same year, Anderson and Parrish described the theory of selective photothermolysis, providing a scientific basis for the improved tattoo removal. Currently, the Q-switched ruby, Nd:YAG, alexandrite and green pulsed dye lasers are all employed in tattoo removal. Each laser enables removal of specific colors of ink; Q-Switched Ruby Laser (blue black, and green) others said (violet and purple) blue, black violet green purple 694 nm, 2040 ns delivers red light that is readily absorbed by tattoo blue, black, and blue black green ink pigments. Excellent results, however, melanin competitively absorbs red light in dark-skinned patients, and can lead to either hypo- or hyperpigmentation abnormalities. Newer ruby LASERs with a shorter pulse duration (approximately 25 ns), higher fluences (8-10 J/cm2), and better beam quality clear tattoos more rapidly. Q-Switched Nd:YAG Laser blue and black delivers infrared light that is absorbed strongly by blue-black tattoo ink, and has less blue black interaction with epidermal melanin than the Q-switched ruby laser. Excellent in all skin types; no hypopigmentation.however, unlike the results with the Qswitched ruby laser, green ink responds poorly. These improvements are attributable to the longer wavelength, higher fluence, and shorter pulse width. These same factors cause more bleeding and tissue splatter during treatment. The faster repetition rate (1-10 Hz) shortens the treatment session, although this is somewhat counterbalanced by the smaller beam size (4 mm vs 5-6.5 mm for the QSRL). Currently, larger spot sizes up to 6 mm are available with new, higher-powered Nd:YAG LASER systems, which also enable deeper penetration and more effective treatment of deeper, denser tattoos. Better beam profiles minimize epidermal damage and decrease bleeding, tissue splatter, and transient textural changes. Q-Switched Alexandrite Laser blue, black, and green blue black Results with blue, black, and green ink removal are variable. blue black has a wavelength of 755 nm, a pulse width of 100 nanoseconds (50-ns pulse width is available in newer models), and a repetition rate of 1 Hz. The 3-mm diameter beam is delivered via a fiberoptic system or an articulated arm. Green Pulsed Dye and Frequency Doubled Q-Switched Nd:YAG (KTP) red& red The flashlamp-pulsed LASER (510 nm, pulse width of 300 100 ns) Both the green pulsed dye (510 nm, 300 ns) and the frequency doubled Q-switched Nd:YAG (532, 10 ns) remove red ink. In addition, some multicolored inks, including orange, purple, yellow, and brown, also respond to these lasers. orange purple yellow brown Histologically, fragmentation of red pigment particles is observed, followed by macrophage engulfment. In addition, because of the epidermal absorption of this LASER, transepidermal ink loss occurs. Summary: Q-switched Nd:YAG and alexandrite lasers are best used for removal of blue - green tattoo
pigments

 Nd:YAG laser works best for red, brown, and orange pigments, Q-switched ruby laser is used to remove tattoos with violet and purple pigments.
Because professional tattoos often extend deep within the dermis, multiple treatments are required.

Treatment Approach Several factors influence the outcome when treating tattoos: 1. patients skin type 2. the color and age of the tattoo 3. whether the tattoo is professional or amateur (material). Amateur, old, black tattoos are the easiest to remove since less ink is usually present. Certain ink colors may be entirely resistant to treatment. Furthermore, darker-pigmented individuals have an increased risk of pigment changes. Treatments can be done at 4- to 8-week intervals until pigment is gone. Immediately after treatment with the Q-switched ruby, Q-switched Nd:YAG, and Qswitched alexandrite laser, whitening occurs and often blood and tissue are splattered. Protective plastic cones and shields are sold with most lasers to confine tissue splatter. Crusting and occasionally blistering occur after treatment. Daily wound care is required with topical antibiotics until skin is intact. Pitfalls While excellent tattoo removal is often achieved using Q-switched lasers, several challenges remain: o Multicolored tattoos, especially fluorescent inks. Since these tattoos are difficult to eradicate, a fair assessment is presented to the patient before treatment is begun. o Irreversible blackening of cosmetic red, flesh-toned, tan, and white inks has occurred after treatment with Q-switched lasers. The presumed mechanism is a conversion of ferric oxide (Fe2O3) to ferrous oxide (FeO). While this darkening does not occur in all cases, patients are warned of the potential. Whenever possible. HISTOLOGY Initially, ink particles are found within large phagosomes in the cytoplasm of both keratinocytes and phagocytic cells (fibroblasts, macrophages, and mast cells). The epidermis, epidermal-dermal junction, and papillary dermis appear homogenized immediately after tattoo injection. At 1 day, 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 that is closely surrounded by collagen. Pigment is not seen within mast cells, endothelial cells, pericytes, Schwann cells, in the lumina of blood and lymphatic vessels, or extracellularly. 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 biopsy specimens obtained at 2-3 months and at 40 years, ink particles are found only in dermal fibroblasts, mostly in a perivascular location under a layer of fibrosis, which replaced the granulation tissue. A prominent network of connective tissue surrounds each of the fibroblasts that contain ink particles, effectively entrapping and immobilizing the cell. The life span of these fibroblasts is unknown and may persist throughout the individual's life.

Ink particles and colors Tattoo particles are initially dispersed diffusely as fine granules in the upper dermis, as well as in vertical foci at sites of injection, but they aggregate to a more focal, concentrated appearance from days 7-13. black ink granules had a mean diameter of 0.5-4.0 m. Turquoise and red pigment particles are approximately twice as large as black granules. Tattoo pigment granules are composed of 3 kinds of loosely packed particles, ranging from 2-400 nm in diameter. The most common particle size is 40 nm, a particle size of 2-4 nm is less common (slightly more electron dense), and a particle size of 400 nm is least common (very electron dense with a crystalline structure). Biopsy samples of older tattoos demonstrate pigment in the deep dermis, in contrast to the more superficial location of newer tattoos. Eventually, tattoo ink appears in the regional lymph nodes of patients with tattoos. To selectively destroy tattoo ink, the best wavelength is chosen to achieve selective absorption for each ink color, while minimizing the nonspecific thermal effects from the primary endogenous chromophores, hemoglobin, and melanin. o Black pigment absorbs at all wavelengths, and competition from melanin absorption in the epidermis decreases gradually as the wavelength increases. o Absorption for blue and green is greatest at wavelengths of 625-755 nm, o red absorbs best below 575 nm. violet is similar to red o Yellow primarily reflects above 520 nm, o orange above 560 nm, o Tan pigment absorbs below 560 nm o flesh-colored pigment below 535 nm. Other obsolete TATTOO REMOVAL TECHNIQUES

Mechanical tissue destruction

high risk of scarring; hypertrophic scars + residual tattoo pigment is common + postoperative pain can be significant. Salabrasion, coarse granules of salt + moist gauze pad for 24 hours. Dermabrasion Surgical excision + skin grafting, multiple-staged excisions, and tissue expanders

Chemical tissue destruction

tannic acid and silver nitrate Intradermal injection of tannic acid Phenol solution or TCA 95%

Thermal tissue destruction

Thermal cryo IR coagulator

Thermal tissue destruction techniques using LASERs

Argon LASER based on selective absorption of energy with vaporization from its 488-nm and 514-nm wavelengths by complementary tattoo pigment colors, its clinical usefulness was limited by melanin and hemoglobin absorption, resulting in unwanted thermal damage. CO2 LASER (X)

Q-switched ruby LASER () Q-switched Nd:YAG LASER () Q-switched alexandrite LASER ()

510-mm 300-nanosecond Candela pigmented lesion dye LASER () ADVERSE EFFECTS

Dyspigmentation and textural changes Allergic reactions Ink darkening (Paradoxic darkening) Epidermal debris

LASER Hair Removal

History of the Procedure: all of the following methods are successful in temporarily removing hair. 1. Manual plucking, tweezing 2. Shaving 3. Waxing (hot or cold) 4. Chemical depilatories 5. Chemical bleaching: Rather than physical or chemical hair removal, 6. Electrosurgery o Electrolysis employs a weak direct current that passes through a negative electrode (anode) inserted in the hair follicle and a positive electrode (cathode) in the form of a wet pad in the patient's hand. Follicular destruction is achieved via the formation of toxic sodium hydroxide (a free radical). o Electrothermolysis uses an alternating current that causes direct thermal destruction of the hair follicle. Etiology: Excessive hair growth is classified into hirsutism and hypertrichosis. Hirsutism

in women excessive hair growth in androgen-dependent areas: androgen production adrenal, ovarian, or exogenous androgen source, and/or skin hypersensitivity to normal or mildly elevated levels of androgens in predisposed individuals. (95% of all cases of hirsutism). Treatment generally aims to suppress ovarian/adrenal androgen overproduction and blocks androgenic action in the skin. Antiandrogens (eg, spironolactone, 5-alpha reductase inhibitors such as finasteride). Hypertrichosis hair growth in a nonandrogen dependent area(s). It can involve coarse terminal hairs or fine vellus or lanugo hairs, presents as a congenital or acquired phenomenon, and varies in extent and severity according to gender and race. Commonly, it is caused by medications such as cyclosporin, oral and topical corticosteroids, and minoxidil. Withdrawing offending agent(s) results in the eventual loss of excessive hair growth. INDICATIONS Patients afflicted with hirsutism < hypertrichosis benefit from LASER-assisted hair removal. Hair Anatomy: Hair follicles (estimated at approximately 5 million per person) cover almost the entire body surface area and can be divided into: o terminal hairs (darkly pigmented, coarse, long) o vellus hairs (lightly pigmented, fine, short). Although vellus hairs outnumber terminal hairs, the latter are more important as they are responsible for enhancing appearance (eg, scalp, beard) and are the cause of distress in some patients because of their excessive number, rapid growth, abnormal distribution, or texture. Hair phases Both terminal and vellus hairs undergo a growth cycle that consists of an anagen (growth) phase, catagen (transitional) phase, and telogen (resting) phase. Duration of each phase and percentages of hairs in each phase vary among different anatomic locations and individuals.

anagen phase last 2-3 years on scalp & 5-7 months on the LL & 1.5-3 months on UL Most of the hair follicles on the scalp are in the anagen phase (85-90%) compared with only (20%) on the LL. Human hair follicles, unlike some animal follicles, exhibit a characteristic feature termed a mosaic pattern = not all of the hair follicles, in any anatomic location, are in concert in their growth phase (ie, while some are in anagen, others are in telogen

or catagen) need for repetitive hair-removal sessions to completely destroy hair follicles. the hair follicle is only susceptible to LASER-induced injury during the anagen phase.

Anatomy of human hair

Human hairs are divided into three anatomic regions. The bulb and superbulb: extend from the lowermost part of the follicle up to the insertion of the arrector pili muscle (bulge region). The bulb encompasses the hair matrix and dermal papilla. The hair matrix, under the control of the dermal papilla, generates the various components of the hair shaft. The isthmus is a short segment that extends from the insertion of the arrector pili muscle to the opening of the sebaceous gland duct. The infundibulum extends from the opening of the sebaceous gland duct to the skin surface. Follicular regeneration Factors governing follicular resting and regrowth remain unknown. There are two main theories for the process of follicular regeneration: Dermal papilla theory: dermal papilla is the crucial site for induction of new hair regrowth. Bulge theory: Alternatively, some authors hypothesize that pluripotential cells in the bulge region (area of insertion of the arrector pili muscle) are responsible for hair regeneration. Destruction of the hair shaft alone does not confer complete hair destruction, as the follicle is still capable of complete regeneration. It appears that the likely target for hair destruction rests in the dermal papilla or bulge region. The bulge region lies approximately 200 m below the skin surface, while the dermal papilla of an anagen hair is 2-5 mm deep and usually situated in the subcutaneous fatty layer. Melanin, the chromophore for almost all LASER-based hair removal systems, is present in the hair matrix, hair shaft, and within melanophages in the dermal papilla. TREATMENT Surgical therapy: LASER-assisted hair removal systems are based on the theory of selective photothermolysis: to preferentially heat and destroy a specific target (eg, melanin for hair removal), choose an appropriate wavelength and set pulse duration < thermal relaxation time (TR for a hair bulb is 20-40 mSec). Melanin has a wide absorption curve without any peaks, unlike oxyhemoglobin, which has two absorption peaks. This absorption curve spans the entire ultraviolet, visible, and infrared light ranges. Practically any wavelength can target melanin.

 However, longer wavelengths (> 600 nm) are preferred for two reasons: Longer wavelengths (e.g. ruby at 694 nm, alexandrite at 755 nm, and Nd:YAG at 1064 nm) offer deeper penetration necessary to destroy the dermal papilla, which lies at 2-5 mm subsurface, (ruby LASER penetrates 1-2 mm, while the Nd:YAG LASER penetrates 4-6 mm). Longer wavelengths offer more protection for melanin-laden epidermis. A large spot size light scattering within the skin relative penetration depth, and ultimately energy density available deep in the skin. (essential for hair removal) The ideal patient has light skin and dark hairs. Long-term efficacy is related mainly to two factors, dark hair and fluence used. Remember red green & blue yellow LASER systems The choice of a particular LASER system and the selection of appropriate parameters (energy fluence, spot size, wavelength, pulse width) should be individualized according to the patient's skin color (Fitzpatrick phototypes), hair density, type of hair, hair shaft diameter, anatomic location, hair color. Epidermal protection is essential to prevent epidermal necrosis and can be achieved by: LASER longer wavelengths. LASER pulse duration > TR of the epidermis (approximately 10 mSec). Cool the skin surface by: o Apply refrigerated ultrasonic gel. o Use a handpiece equipped with a chilled-tip sapphire lens or water-cooled glass. o By pressing the tip against the skin in the treated area, it shortens the distance that photons have to travel to their target; additionally, this pressure empties the capillary loops and dermal microvascular plexus, minimizing the photons' inadvertent competitive absorption by hemoglobin. o Use a cryogen spray device (tetrafluoroethane Freon 134A). Mechanisms for hair removal with light Light can destroy hair follicles by thermal (due to local heating), mechanical (due to shock waves or violent cavitation), or photochemical (due to generation of toxic mediators like singlet oxygen or free radicals) mechanisms. A- Photothermal destruction In the visible to near-infrared region, melanin is the natural chromophore for targeting hair follicles. LASERs or light sources that operate in the red or near-infrared wavelength region (694-nm ruby, 755-nm alexandrite, 800-nm diode, 1064-nm Nd:YAG, and noncoherent light sources with cut-off filters) deep and selective heating of the hair shaft, the hair follicle epithelium, and the heavily pigmented matrix (600- to 1100-nm) The melanin-rich hair shaft and matrix cells occupy a relatively small volume, and propagation of the thermal damage front through the entire volume takes 3-20 times >TR of

the hair follicle. Superlong-pulse heating (>100 milliseconds) appears to allow for longterm hair removal. B- Photomechanical destruction with very short nanosecond pulses by Q-switched 1064-nm Nd:YAG LASERs, + carbon suspension extremely rapid heating of the chromophore (melanin) occurs generates photoacoustic shock waves focal photomechanical disruption of the melanocytes but not complete follicular disruption. Therefore, this LASERs are not likely to produce longterm hair removal. C- Photochemical destruction of hair follicles Photodynamic therapy is the use of light + a photosensitizer [ALA is a precursor in porphyrin synthesis and is rapidly and selectively converted to protoporphyrin IX by cells derived from the epidermis and follicular epithelium] absorption of a photon protoporphyrin IX efficiently crosses into an excited triplet state generates singlet oxygen by collision with ground-state oxygen a potent oxidizer that damages cell membranes and protein. This approach will potentially provide an effective means of treating nonpigmented hair. A distinction needs to be made between permanent and complete hair loss. Complete hair loss refers to a lack of regrowing hairs (ie, a significant reduction in the number of regrowing hairs to zero). Complete hair loss may be either temporary or permanent. LASER treatment usually produces complete but temporary hair loss for 1-3 months, followed by partial but permanent hair loss. Immediately after LASER treatment, the hair shaft shows fragmentation with focal rupture into the follicular epithelium and thermal damage to the surrounding follicular epithelium. The extent of thermal damage is dependent on the pulse width but retains confinement on the spatial scale of the follicle itself. One month later, most follicles are in telogen phase while others are being replaced by fibrosis and a foreign body giant cell reaction with phagocytosis of melanin. At 1 year, most follicles are replaced by miniaturized hair follicles (dominant mechanism), and some are replaced by a fibrotic remnant. Both of these histological findings produce permanent clinical reduction in hair.

Modalities used in LASER hair removal: A- Short pulsed QS LASERs Q-switched Nd:YAG LASER at 1064 nm. Two methods for hair removal: 1. wax epilation of the hairs Apply an exogenous carbon suspension to the treatment area QS Nd:YAG short pulses (~ 10 nanoSec) and low-energy fluences (2-3 J/cm2). (Carbon serves as the chromophore ensuing photomechanical (explosion of carbon particles) and photothermal effects destruction of the hair follicle). 2. Alternatively, without the exogenous carbon suspension or waxing. (Intrinsic melanin of the hair serves as the chromophore. QS Nd:YAG at a repetitive rate of 1-10 Hz and energy density of 8-10 J/cm2. Advantages include: light-colored hairs (blond, gray, white) can be treated in 1st method

speed in 2nd method Disadvantages 1. No benefit when using pretreatment waxing or carbon suspension 2. Laborious, (1st method) 3. Untidy, since carbon particles and hair fragments splatter, contaminating the surrounding field 4. Not effective for long-term hair removal. Showed efficacy in retarding short-term hair regrowth B- Long pulsed LASERs Four wavelengths are used to remove hair. 1. Long pulse (normal mode) ruby Laser at 694 nm 2. Long pulse Alexandrite Laser at 755 nm 3. Long pulse Diode Laser at 800-810 nm 4. Long pulse Nd:YAG Laser at 1064 nm Advantages: o Availability of surface cooling o Epidermal protection (from surface cooling and longer pulse duration) o Effective for long-term hair removal o Nd:YAG 1064 nm system may be best for darkly pigmented patients The disadvantage is that it is not effective for lightly pigmented hairs. C- Intense-pulsed noncoherent light This system is not a true LASER (emits noncoherent light in various wavelengths). The system is equipped with computerized software that selects, depending on the patient's skin color, hair color, and hair shaft thickness, the suitable cut-off filter, energy density (30-65 J/cm2), pulse duration (2.5-7 ms), interpulse delay (1-300 ms), number of pulses (2-5). Cut-off filters (590, 615, 645, 695 nm) abolish shorter wavelengths and permit only longer wavelengths to be discharged. Spot sizes are 10 x 45 mm or 8 x 35 mm, repetition rate is 0.3 Hz. Epidermal cooling is achieved via refrigerated cooling gel. Advantages: o able to treat a variety of skin phototypes and hair colors. o effective in long-term hair epilation. The disadvantage is the complex, long learning curve to operate the device. D- Photodynamic therapy using a topical photosensitizer (ie, 5-alpha aminolevulinic acid [ALA]) under occlusion [ALA tends to localize in the follicular epithelium] after 14-18 hours irradiation of UVA-visible-near IR light (350-800 nm) absorb photons generation of O3 singlets (Oxygen Free Radicals) selectively hair destruction. Advantages o ability to treat all hair colors o a LASER system is not required, (non-LASER light sources are adequate) o less costly. Disadvantages o The therapy is painful. o Time consuming:. o Long-term studies of PDT for hair removal are not available yet.

Temporary hyperpigmentation has been observed.

Preoperative Evaluation: 1- Identify the cause: (hypertrichosis X hirsutism): personal and family history, amount and distribution of excessive hair growth, onset, previous treatments, and drug history, menstrual irregularities, nipple discharge, difficulty conceiving, scalp hair loss, or cystic acne. 2- Take a detailed medical history to exclude photosensitizing disorders or medications, collagen vascular disease, or immunosuppression. 3- Check for history of scarring or keloid formation after skin injury. 4- In bikini area or perioral area check for a history of herpes simplex. 5- Avoid treating skin darker than Fitzpatrick IV phototype. Pretreatment protocol Avoid the sun and use sunscreen. hydroquinone 4% cream twicw daily with darker skin phototypes. Avoid waxing or tanning for 4 - 6 weeks; however, allow shaving and chemical. Topical anesthetics can be used. Intraoperative details: Observe LASER safety at all times. Proper eye protection is mandatory for the patient and LASER operator as well as additional persons present in the LASER suite. Trim hair as short as possible; long hair absorbs some of the LASER energy skin burn. Remove all cosmetics, lubricants, and anesthetic creams and clean and dry area. Epidermal cooling is essential. Individualize treatment parameters (skin phototype, hair color, hair shaft diameter, anatomic site, and prior treatment responses). Start with lower energy fluences and increase energy. Treatment endpoints may not be apparent for 2-5 minutes. Thus, one should observe this time gap, especially in the beginning of each treatment session or when parameters have been changed, to avoid unnecessary increase in LASER energy that may lead to potential complications. o Perifollicular erythema o Perifollicular edema o burning of hair (in some devices) o Immediate photoepilation (occasionally seen) Avoid overlapping pulses more than 10-15%. Signs of skin injury o Blistering o Tissue whitening o Intense erythema o Intense edema o Intense pain (very important sign, especially in darker skin phototypes) Postoperative details: Ice packs. Alternatively, a potent topical corticosteroid. topical antibiotic cream for infection prophylaxis. Oral antibiotics extensive skin damage. Reintroduce hydroquinone 4% cream the day following LASER hair removal. When treating an extensive area such as the arms or legs, applying an emollient (ie, 12% ammonium lactate cream) twice daily is often helpful. Inform the patient that shedding of hair in the treatment area is expected in the first 1-2 weeks and does not imply new hair regrowth.

COMPLICATIONS

Activation of herpetic infection: Bacterial infection: SUMMARY

Pigmentary alteration: Scarring:

Endogenous chromophores
1234567Ruby LASERs Alexandrite LASERs Diode LASERs (800 nm) Q-switched Nd:YAG LASERs (1064 nm) Long-pulse Nd:YAG LASERs Pulsed, noncoherent broadband light sources Electro-Optical Synergy technology

Exogenous chromophore
1- Carbon suspension Q-switched Nd:YAG LASERs 2- Meladine 3- Aminolevulinic acid Hair color Patients with dark hair are mostly likely to obtain long-lasting hair removal, while blonde-, red-, gray-, or white-haired patients are unlikely to experience a permanent reduction. blond, gray, white, or red hair exogenous chromophore Skin color Fair-skinned patients with dark hair are most easily treated. persons with dark skin types are not readily treated with any of the ruby LASERs because of melanin interference, the alexandrite and diode LASERs and the intense pulsed light sources, operating at longer wavelengths (near infrared) and longer pulse durations, have been shown to treat persons of darker skin types (Fitzpatrick phototype IV-V) more safely if combined with cooling devices. Q-switched Nd:YAG LASER, with or without an external chromophore, has been shown to be very useful for the treatment of dark skin types but appears to be ineffective for permanent hair removal. Long-pulsed, 1064-nm Nd:YAG LASERs may be the safest way to treat patients with dark skin tones.

OTHER USES of Photodynamic therapy in dermatology

Benign skin conditions
1234Psoriasis Human papilloma virusassociated skin diseases Vascular malformations Disorders of pilosebaceous units

Premalignant skin conditions Malignant skin conditions

1234Bowen disease Invasive squamous cell carcinoma Basal cell carcinoma Mycosis fungoides 5- Malignant melanoma 6- Extramammary Paget disease 7- Metastatic carcinoma

LASER Treatment of Benign Pigmented Lesions

Remember red green & blue yellow

 Q-switched ruby LASER targeted individual melanosomes. LASER irradiation leads to histologic melanosomal disruption and vacuolization of pigment-laden cells in the basal layer. Both keratinocytes and melanocytes exhibit pigment and nuclear material condensation at the periphery of LASER-irradiated cells. This leads to a characteristic "ring-cell" appearance. Epidermal necrosis and regeneration of a pigmented epidermis follow over the next 7 days. Melanosomes are 0.7 m in diameter in types I and II skin & 1 m or more in diameter in darker skin types have very short TRT. The threshold exposure for immediate skin whitening, the sign of LASER-induced melanosomal changes, is wavelength-dependent.
GREEN-LIGHT PULSED AND GREEN-LIGHT NONPULSED LASERS Melanosome in skin types III, IV, V, and VI

Green-light pulsed LASERs flashlamp-pumped pulsed dye , frequency-doubled Q-switched Nd:YAG. These produce energy with pulses shorter < TRT of melanosomes. Both produce excellent results in epidermal pigmented lesions such as solar lentigines, seborrheic keratoses, caf au lait macules , Becker nevi, speckled nevi, and congenital melanocytic nevi green wavelength of these Lasers is also well absorbed by oxyhemoglobin purpura, which resolves 1-2 weeks. Treatment results are affected by anatomic location. (hand and face > trunk or leg) Green-light nonpulsed (quasi-continuous wave) LASERs copper vapor (511 nm), krypton (520-530 nm), and variable pulse with potassiumtitanyl-phosphate (KTP) (532 nm) Lasers share some characteristics with the previous pulsed LASERs. However, because the > TRT of melanosome they do not produce the same consistent clinical results. more treatment sessions are usually necessary to achieve similar results as pulsed LASERs. These LASERs are not useful in dermal pigmented lesions such as nevi of Ota. RED-LIGHT PULSED LASERS Melanosome in skin types III, IV Q-switched ruby and Q-switched alexandrite LASERs. Q-switched ruby (694-nm with a 20- to 50-nanosecond pulse duration). Q-switched alexandrite (755-nm with a pulse duration of 50-100 nanoseconds). The longer wavelengths of both allow deeper penetration into the dermis. Their mechanism of action on melanin-containing melanosomes and melanocytes involves selective photothermolysis, photoacoustical mechanical disruption, and chemical alteration of the target tissue. effective at lightening brown, blue, and black macules. Penetrate up to 1 mm of skin The Q-switched Nd:YAG LASER is the optimal LASER for treating melanocytic processes in skin types III, IV, V, and VI, in particular for dermal processes such as the nevi of Ota or Ito. This LASER can also be used to treat blue nevi. The Q-switched ruby LASER is highly effective in treating dermal pigmented lesions (eg, nevus of Ito and Ota). NORMAL-MODE ALEXANDRITE AND RUBY LASERS

Recently, long-pulsed ruby (300- to 3000-microsecond pulses) and alexandrite (2- to 20microsecond pulses) LASERs were shown to be effective in the treatment of Q-switched ruby LASERresistant congenital nevi and other pigmented lesions. These LASERs also may be of use in LASER-assisted hair removal. The normal-mode alexandrite LASER emits light at a wavelength of 755 nm with 2- to 20-microsecond pulse durations. This LASER is effective in removing pigmented hair. No data have been published on its use in pigmented lesions. NEAR-INFRARED PULSED LASERS The Q-switched Nd:YAG LASER produces a 1064-nm wavelength beam with a pulse duration of 10 nanoseconds. Melanin does not absorb the 1064-nm wavelength well. Thus, it is not ideal for the treatment of benign pigmented lesions. However, its advantage lies in its ability to penetrate more deeply into the skin (up to 4-6 mm). May be more useful in the treatment of lesions in individuals with darker skin tones. Similar to Q-switched ruby and alexandrite, it is highly effective for clearing nevi of Ota. Histologically, identical to those of the Q-switched ruby LASER Ring cells NONSELECTIVE LASER TECHNIQUES: CO2 AND Er:YAG LASERS thermal damage (Er:YAG < CO2). Thermal damage occurred in the basal cell layer (vacuolization and spindling of the melanocytes and keratinocytes). This damage led to epidermal necrosis 24 hours later with subsequent dermal-epidermal separation. Minimal dermal thermal damage occurred. Sloughing of the damaged epidermis was followed by subsequent reepithelialization.
Summary Q-switched ruby LASER (694 nm) Q-switched Nd:YAG (1064 nm) Q-switched Nd:YAG (532 nm) Green pulsed Dye (510 nm) Alexandrite 755 nm Nonnevocellular Epidermal Excellent Fair Excellent Excellent Good Pigmented Lesions Dermal Excellent Excellent Poor to fair Fair Good Mixed Poor Poor Poor Poor Poor

LASER Treatment of Acquired and Congenital Vascular Lesions

INTRODUCTION

 The targeted chromophore for vascular lesions is intravascular oxyhemoglobin; thus, oxyhemoglobin thermal damage is largely restricted to cutaneous blood vessels. Remember red green & blue yellow Transient purpura is the most common adverse effect Currently, dynamic surface cooling and extended pulse duration, which enhance clinical results and minimize adverse effects. CLASSIFICATION OF CUTANEOUS VASCULAR LESIONS Cutaneous vascular lesions are categorized according to mode and age of onset: Congenital lesions begin in infancy and include port-wine stains, hemangiomas, venous malformations, and lymphangiomas. o Congenital lesions are found most commonly on the head or neck and may be isolated or
found as part of a congenital syndrome such as Sturge-Weber syndrome.

Acquired lesions develop in persons of any age and include telangiectasias, cherry angiomas, pyogenic granulomas, venous lakes, poikiloderma, and Kaposi sarcoma.
o Acquired lesions may occur spontaneously, or they may be caused by trauma, ultraviolet exposure, or hormonal changes.

Congenital lesions
Port-wine stains nevus flammeus capillary malformations Hemangiomas benign proliferations of blood vessels Lymphangiomas slow-growing lymphatic malformations that can be acquired after lymphatic drainage obstruction, chronic inflammation, infections, trauma, or surgical procedures most are congenital and likely arise from a combination of abnormal budding of lymphatic structures, failure of venous vasculature to unite with the lymphatics, and atypical lymphatic tissue sequestration during embryogenic development. at birth, 2 years soft tissue masses in the axillae or neck regions, tongue,

Definition Age
Incidence

Site course

At birth : Equal 0.3-0.5% face, and the V2 dermatome Lesions without regression Initially appearing as light-pink macules, portwine stains can darken over time as a result of progressive vessel ectasia. Overlying soft tissue or bony hypertrophy may be associated with these lesions. PDL

C/P

Laser used

at birth, 1 year 10-12% solitary lesions that occur on the head or neck rapid growth phase before involuting after undetermined amount of time (1-12yr) Associated complications include ulceration, bleeding, infection, and scarring. Rapidly proliferating hemangiomas of the face are particularly concerning because they may compromise vital structures or obscure vision Large hemangiomas may be associated with Kasabach-Merritt syndrome CW-PDL, excisional surgery, CW-PDL systemic corticosteroids, interferon, imiquimod, and cryosurgery

classified as superficial lesion is lymphangioma circumscriptum, deep lymphatic malformation cystic hygroma

Surgical excision is typically the preferred treatment modality, sclerosing agents, argon beam, PDL, Nd:YAG, CO2 PDL,

Hemangiomas

Vascular malformation

Presentation

age sex course

Radiographic evaluation

At birth, except for AVMs, commonly manifest later in childhood or adolescence : 3:1 : 1:1 proportionate growth throughout the life, with Rapid for 8-12 months slow hormonal changes (eg, puberty, pregnancy), spontaneous over 5-8 years infection, trauma, or surgical intervention rubbery, firm, well-circumscribed - Capillary: well-circumscribed macular lesions, lesions commonly occur on the face in the trigeminal - superficial dermis: proliferation of distribution. cells causes the skin to become raised - Venous and lymphatic: are not as well and bright red circumscribed, soft, readily compressible, and - deeper dermis or subcutaneous nonpulsatile. tissues: less demarcated may have a Expansion occurs in venous malformations with bluish hue compression of the jugular vein on the affected side, performance of the Valsalva maneuver, or dependent positioning. - AVMs: warm, firm masses with thrills, bruits, and pulsatility. o differentiating deep hemangiomas from venous or lymphatic malformations o assessing the true extent of soft tissue involvement o imaging modalities often highlight distinguishing characteristics o U/S accurately determine the flow characteristics of the lesion o CT scan assessing the extent of soft tissue involvement, or bony erosion or remodeling o MRI the most information to evaluate cervicofacial vascular anomalies

At birth

Physical examination

AVMs and proliferating hemangiomas high-flow characteristics (but can be

distinguished by the decreased relative parenchyma of AVMs). Venous and lymphatic malformations low-flow lesions, (consisting predominantly of different-caliber vessels without intervening parenchyma)

Acquired lesions
Telangiectasias small, dilated vessels that are 0.1-1.5 mm in diameter. commonly occur on the face and lower extremities. Facial telangiectasias can occur spontaneously, or they can be caused by excessive UV exposure, collagen-vascular disease, acne rosacea, pregnancy, alcohol or estrogen ingestion, or topical corticosteroid application. Lower extremity telangiectasias are more common in women and may be genetic or may develop after pregnancy. Treatment options: sclerotherapy, electrodesiccation, and IPL or LASER therapy. Shorter wavelengths <600 nm are more effective for treating redder, more superficial vessels, Longer wavelengths >600 are successful for deeper blue venulectasia and reticular veins. Sclerotherapy with 0.25% sodium tetradecyl sulfate significant clinical improvement was seen in LL. Temporary postinflammatory hyperpigmentation was seen only with sclerotherapy. effectiveness of LASERs for facial telangiectasias, treatment of lower extremity telangiectasias with vascular-specific LASERs can be ineffective. Treatment failures are often attributed to the larger size and deeper site of lower extremity vessels and their association with deeper, feeding venous plexuses. For these reasons, sclerotherapy is considered first-line treatment for most telangiectatic leg veins. Cherry angiomas small, well-circumscribed, bright-red vascular proliferations, early adulthood and in number with age. benign, treated with vascular-specific LASERs to improve cosmesis.

Pyogenic granulomas an acquired, benign, vascular cutaneous tumor that can also affect mucous membranes. commonly found in infants and children, 0.5% of all skin nodules in children. Clinically, pyogenic granulomas usually manifest as hard, red papules on the head and neck that are rapidly enlarging; they frequently bleed or ulcerate. Treatment options include surgical excision, shave excision with concomitant electrodesiccation to the base, electrocautery alone, PDLs, and copper Laser systems. PDLs Poikiloderma Poikiloderma of Civatte clinically appears as a reticulated, brown pigmentation of the neck, anterior chest, and lower face with prominent telangiectasias caused by chronic sun exposure. Poikiloderma may be successfully treated with either the PDLs or IPL. The intense pulsed-light source may prove more helpful in eliminating associated hyperpigmentation because of its additional effect on epidermal melanin; however, it is more difficult to use, particularly in thin-skinned areas such as the neck and chest. THE LASER SYSTEMS Argon LASER It emits blue-green light, within 488- to 514-nm. CW, with spot sizes ranging from 0.1-1 mm, tissue penetration depths of 1-2 mm. energy is predominantly absorbed by oxyhemoglobin, it is also absorbed to some degree by epidermal and dermal melanin (shorter wavelength) + CW mode >TRT of the vascular target associated with a higher prevalence of postoperative pigmentary alteration and fibrosis not useful in darkerskin. small spot size (up to 1 mm, compared with 10 mm for the PDL) also limits effective dermal penetration, further contributing to clinical inefficacy. However, it is the most successful treatment for certain acquired vascular lesions, including telangiectasias, cherry angiomas, and angiokeratomas. Argon-pumped tunable dye LASER The argon-pumped tunable dye LASER (APTDL) is a quasi-CW mode LASER with high specificity for cutaneous vascular structures. wavelengths 488-638 nm operated in the yellow 577- to 585-nm range for improved absorption by hemoglobin. can be shuttered pulse durations as short as 20 milliseconds, (most clinical applications require at least a 100-millisecond duration), Adverse effects include atrophic scarring, hypertrophic scarring, and permanent pigmentary alteration. Potassium titanyl phosphate crystal (KTP) LASER KTP =1064-nm Nd:YAG source passed through a KTP crystal to emit light that is frequency-doubled with a wavelength of 532 nm. quasi-CW LASER system uses nanosecond pulses to destroy vascular targets. The KTP LASER's 532-nm wavelength corresponds with the 542-nm absorption peak of oxyhemoglobin, which makes it relatively specific for cutaneous blood vessels. Although the short wavelength does not allow for deep tissue penetration, extended pulse durations up to 50 milliseconds improve its effectiveness. often used to treat telangiectasias, and multiple treatments are necessary for largercaliber vessels. Similar to the quasi-CW argon system, less purpura, swelling, and pain.

Copper vapor and copper bromide LASERs Copper vapor and copper bromide LASERs emit greenish-yellow light with a wavelength of 578 nm. These quasi-CW mode LASERs deliver rapid, 20-nanosecond pulses at a repetition rate of 6,000-15,000 pulses per second Therefore, better for the treatment of largercaliber vessels with longer thermal relaxation times because they have a tendency to produce increased thermal necrosis in tissue. Facial telangiectasias, cherry angiomas, and pyogenic granulomas. Absorption of energy by epidermal and dermal melanin also occurs, making postoperative pigmentary alterations common the use should be restricted to patients with Fitzpatrick skin phototypes I-II. Other posttreatment adverse effects include fine crusting and blistering that usually resolve over a 2-week period. Krypton LASER a quasi-CW mode LASER that emits green light at 520-530 nm and yellow light at 568 nm. The 568-nm has been used for the treatment of facial telangiectasias. Vessels are traced using a 1-mm handpiece with pulse duration of 0.2 seconds and power settings ranging from 0.5-0.75 W until the vessel disappears completely. As with other quasi-CW systems, multiple treatment sessions at 3- to 4-week intervals are often necessary. The most common adverse effects include erythema, edema, and mild blistering or crusting. Flashlamp-pumped PDL The PDL was originally available at a wavelength of 577 nm, corresponding directly with the third absorption peak of oxyhemoglobin, and a pulse duration of 450 microseconds. Chromophore is oxyhemoglobin contained within vascular lumina thermal damage to other structures. a newer 595-nm ultralong-PDL can be adjusted for pulse durations from 1.5-40 milliseconds. It has a cryogen-cooling device to decrease pain and adverse effects (eg, purpura). The PDL is considered the criterion standard treatment for port-wine stains, The PDL is useful in the treatment of superficial hemangiomas and in a variety of acquired cutaneous vascular lesions, including telangiectasias, cherry angiomas, pyogenic granulomas, and poikiloderma of Civatte. Pyogenic granulomas Intense pulsed noncoherent light A noncoherent pulsed-light source that emits light within the 500- to 1200-nm portion of the electromagnetic spectrum can also be used to treat a variety of cutaneous vascular disorders. Depending on lesion type and size, cutoff filters of varying wavelengths (515 nm, 550 nm, 570 nm, 590 nm) are used to eliminate shorter wavelengths. Light is delivered in a train of single, double, or triple pulses (2-25 milliseconds each) with varying time intervals between pulses (10-500 milliseconds). This system is highly operator-dependent and allows treatment parameters (ie, wavelength, pulse duration, delays between pulses) to be tailored for each use. used to treat port-wine stains, hemangiomas, and facial or lower extremity telangiectasias. Smaller-caliber vessels respond best to treatment with lower cutoff filters (515 or 550 nm); larger-caliber vessels require longer-wavelength filters to effect deeper tissue penetration.

Sclerotherapy
TREATMENT Surgical therapy: Four basic techniques may be used for the treatment of telangiectatic and reticular veins. These include the following: Aspiration technique: The aspiration of a small amount of blood may ensure that the clinician has cannulated the vessel adequately. This is necessary for the more concentrated dilutions because misplacement may cause dermal necrosis. Puncture fed technique: This is accomplished as the clinician feels the needle hub penetrate the vessel. Then, the sclerosant is injected. This technique works well for experienced clinicians, but it may be hazardous for novices. Air bolus technique: The injection of 0.5 mL of air prior to the introduction of sclerosant reveals blanching and soft tissue prior to sclerosant injection. Empty vein technique: This technique is more important for the treatment of larger veins. The vein is evacuated; therefore, a smaller amount of sclerosant is necessary to contact the intraluminal surface than with a distended vein. The sclerosant that offers the best chance of optimal results in the sclerotherapist's hands: polidocanol (Aethoxysklerol) sodium tetradecyl sulfate (Sotradecol) hypertonic saline. Both polidocanol and sodium tetradecyl sulfate are detergents and act as irritants to the intimal of the capillary vessels. Polidocanol remains available. Hypertonic saline is the most commonly used agent in the United States. COMPLICATIONS Complications include telangiectatic matting, infarction with skin slough, cellulitis, phlebitis, and thrombophlebitis. SUMMARY Optimal efficiency in treating common leg telangiectasias may often be achieved with a combination of sclerotherapy followed by LASER or IPL. sclerotherapy to treat the larger, feeding venous system, LASER or IPL effectively seals the superficial vessels to prevent extravasation, thereby theoretically minimizing pigmentary changes, recanalization, and telangiectatic matting. Combined technologies, especially those using radiofrequency, seem to hold promise as emerging alternatives in the realm of LASER treatments to sclerotherapy in the treatment of smaller veins.